an atlas of investigation and management paleri • hill ent ... infections chp 1.pdf · an atlas...

Paleri • H

ill

An Atlas of Investigation and Management

ENT INFECTIONSAn illustrated guide to the investigation, diagnosis andmanagement of infectious diseases of the ear, nose andthroat. The authors lead the reader through physicalexamination followed by an overview of the microbiologyof ENT infections, describing the main infective organismsand the tests by which the presence of bacterial, viral,fungal and other infections can be confirmed. This isfollowed by a brief summary of the principles ofpharmacological management, the agents currently in use and their mode of action.

The ensuing sections of the atlas focus separately oninfections of the ear, the nose and paranasal sinuses, themouth, the pharynx, the larynx and the neck. All chapterspresent an illustrated discussion of relevant infections,covering various possible diagnoses, the causativeorganisms and the means by which the infection can betreated. Information is supported by high quality colourphotographs, diagnostic algorithms and tables throughout.The concluding chapter deals with some of the mostimportant tropical infections which are encountered withincreasing frequency and with which the clinician needs tobe familiar.

Related title:Problem Solving in Infection, S Dancer, A SeatonISBN 978 1 904392 83 5

Website: www.clinicalpublishing.co.uk

ISBN: 978 1 84692 006 6

ENT Infections CMYK

ENT INFECTIONSVinidh Paleri • John Hill

CLINICAL PUBLISHING


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DedicationThis book is dedicated to the memory of both our fathers.

They inspired us, believed in us, and were our heroes.

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ENT INFECTIONSVinidh Paleri

Consultant Surgeon and Honorary Senior LecturerDepartment of Otolaryngology – Head and Neck Surgery

Newcastle-upon-Tyne HospitalsNewcastle-upon-Tyne, UK

John HillConsultant Surgeon and Honorary Senior Lecturer

Department of Otolaryngology – Head and Neck SurgeryNewcastle-upon-Tyne Hospitals

Newcastle-upon-Tyne, UK

CLINICAL PUBLISHINGOXFORD

ENT Final.qxd:Dementia final.qxd 12/2/10 06:23 Page iii

Clinical Publishing

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© Atlas Medical Publishing Ltd 2010

First published 2010

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,

in any form or by any means, without the prior permission in writing of Clinical Publishing or Atlas Medical

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to our attention.

A catalogue record of this book is available from the British Library

ISBN print 978 1 84692 006 6

ISBN e-book 978 1 84692 607 5

The publisher makes no representation, express or implied, that the dosages in this book are correct.

Readers must therefore always check the product information and clinical procedures with the most

up-to-date published product information and data sheets provided by the manufacturers and the most

recent codes of conduct and safety regulations. The authors and the publisher do not accept any

liability for any errors in the text or for the misuse or misapplication of material in this work.

Printed by Marston Digital Ltd, Didcot, Oxon, UK

ENT Final.qxd:Dementia final.qxd 12/2/10 06:23 Page iv

Contents

Foreword viiPreface viiiAcknowledgements viiiContributors xiAbbreviations x

1 Clinical examination 1Ear 1JOHN HILL

Examination of the ear 1

Nose 3WOLFGANG ISSING

Examination of the nose 3Radiological examination 3

Oral cavity, oropharynx, larynx and hypopharynx, and neck 5VINIDH PALERI

Examination of the oral cavity 5Examination of the oropharynx 7Examination of the larynx and hypopharynx 7Examination of the neck 8

2 Microbiology of ENT infections 11MANJUSHA NARAYANAN

Microorganisms that cause human infections 11Commensals 13Principles of microbiological diagnosis 13Causative organisms 18

Upper aerodigestive tract and sinus infections 19Ear infections 19

3 Principles and practice of anti-infective therapy in ENT infections 21VINIDH PALERI AND JOHN HILL

Introduction 21Resistance 21Parenteral therapy 22Frequently used antibiotics in ENT practice 22Choice of antibacterial therapy 24

4 Infections of the ear 25JOHN HILL

Introduction 25Infections of the pinna 25Infections of the external ear canal 25

Furunculosis 26Acute otitis externa 26Chronic otitis externa 28Fungal otitis externa 30Sequelae of chronic otitis externa 30Viral infections 31Bullous myringitis 31Herpes zoster 31

Infections of the middle ear 32Viral acute otitis media 32Acute otitis media 32Acute mastoiditis 33Infected perforated tympanic membrane 34Infected grommets or ventilation tubes 34Cholesteatoma 36Infected mastoid cavity 39Aural polyp 39Ototoxicity 41

Infections of the inner ear 41Osteomyelitis of the skull base 41Pyogenic infection of the inner ear 42Bell’s palsy 42Vestibular neuronitis or labyrinthitis 42

5 Infections of the nose and paranasal sinuses 43WOLFGANG ISSING AND ANDREAS LEUNIG

Introduction 43Infections of the external nose 43

Erysipelas 43Herpes simplex 43Fistula of the nasal dorsum 44Foreign bodies 44

Infections of the nasal cavity 45Vestibulitis 45Viral papilloma 45Septal haematoma and septal abscess 45Nasal polyposis 47

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Nasal foreign bodies 47Adenoiditis 47

Infections of the paranasal sinuses 48Rhinitis, sinusitis, and rhinosinusitis 48Viral rhinosinusitis 48Acute and chronic bacterial rhinosinusitis 48Fungal sinusitis 50Complications of paranasal sinus infections 50Orbital cellulitis 50Pott’s puffy tumour (osteomyelitis of the frontal bone) 52Frontal sinus mucocoele and pyocoele 50

6 Infections of the oral cavity 55VINIDH PALERI AND KONRAD STAINES

Introduction 55Viral infections 55

Primary herpetic gingivostomatitis 55Recurrent herpetic infections (cold sores) 57Chickenpox (varicella) 57Shingles (zoster) 57Hairy leukoplakia 58Papillomatosis 58

Bacterial infections 58Acute ulcerative gingivitis 58

Fungal infections 61Candidiasis 61

7 Infections of the oropharynx 65VINIDH PALERI


Infectious mononucleosis 67Herpes simplex 68Human papilloma virus 68

Bacterial infections 69Group A beta haemolytic streptococci (GABHS) 69Diphtheria 69Peritonsillar abscess 70Candida 71

8 Infections of the salivary glands 73VINIDH PALERI


Mumps 73Human immunodeficiency virus 74

Bacterial infections 74

Acute suppurative sialadenitis 74Submandibular salivary gland infections 76Chronic recurrent parotitis of childhood 77Granulomatous infections 77Tuberculosis 77

9 Infections of the larynx 79VINIDH PALERI

Introduction 79Laryngeal infections 80

Supraglottitis in children 80Supraglottitis in the adult 81Laryngotracheobronchitis (croup) 81Bacterial tracheitis 82Chronic infective laryngitis 82Laryngeal papillomatosis 84Laryngopyocoele 84Chondronecrosis 84

10 Infections of the neck 87VINIDH PALERI

Introduction 87Neck infections 87

Cervical lymphadenitis 87Monomicrobial infections 88

Cat scratch disease 88Toxoplasmosis 89Mycobacterial infections 89Actinomycosis 90

Polymicrobial infections 90Cellulitis of the neck 90Necrotizing cervical fasciitis 91Infection of branchial and thyroglossal cysts 91Deep neck space infections 93Post-operative infection 97Infective thyroiditis 98Atlanto-axial subluxation (Grisel syndrome) 98

11 Tropical ENT infections 101SURIANARAYANAN GOPALAKRISHNAN AND

VINIDH PALERI

Common infections 101Rhinoscleroma 101Leishmaniasis 102Rhinosporidiosis 103Leprosy of the nose 103Anthrax 104

Index 105

Contentsvi

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Foreword

It is indeed a great honour and pleasure to be asked to writea Foreword to accompany this publication. ENT Infections:an Atlas of Investigation and Management is a qualitypublication which brings together clinical scenarios thatpresent to a diversity of clinicians on a daily basis. Bydividing the ear, nose, and throat into its appropriateanatomic sites, the consulting clinician can refer to the Atlasand confirm with a greater degree of accuracy what thediagnosis is or likely to be. As well as covering the principlesof microbiology and anti-infective therapy, this Atlashighlights the need for an appropriate physical examinationof each anatomic area. Each chapter is lavishly illustratedwith pictures of pathologies and clinical scenarios andincludes algorithms and tables where needed. The additionof a chapter on tropical infections will be welcomed by manywho will purchase this publication.

The authors, both Consultants in Otolaryngology – Headand Neck Surgery, at Newcastle-upon-Tyne Hospitals, areprofessionally aware that lack of knowledge amongclinicians, general practitioners, and hospital consultantsabout the conditions and diseases that affect the ear, nose,and throat may result in inappropriate treatment. Forexample, the majority of acute symptoms that develop inENT are labelled as casued by ‘an infection’ with the result

that each such clinical scenario is treated by a course of ‘anantibiotic’. While the result of such intervention would seemappropriate as the condition, in the acute phase, seems toabate with the easing of ‘pain’ symptoms, often the infectionlingers with the result that it returns with a vengeance withina short period of time. The symptom of ‘sore throat’,depending on the age of the patient, maybe called tonsillitisor pharyngitis, but is usually treated the in the same way;and in the older or elderly patient when such symptomspersists for weeks and, perhaps, months, the incorrectdiagnosis of a ‘throat cancer’ is not infrequently made.Sometimes, what appears to be a ‘simple sore throat’ maybecome a life-threatening condition, such as a para -pharyngeal abscess or epiglottitis, which if not treatedcorrectly may result, tragically, in death.

I would recommend this publication to all professionalswho are exposed to acute clinical scenarios, from paediatricsto care of the elderly. This book will also be invaluable tomedical, dental, and nursing students, providing afoundation for future clinical experiences and expertise.

Patrick J Bradley, MBA, FRCSProfessor of Head and Neck Oncologic Surgery

The University of Nottingham

vii

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viii

Preface

eschewing exotic disease presentations. This book is asource of concise and easily accessible information on allcommon infections of the ear, nose, mouth, throat, andneck. It is suitable for clinicians working in primary care,junior hospital doctors, and nurses who routinely oroccasionally care for patients with these infections. We alsohope that this book will satisfy its aim of being a referencemanual for other senior clinicians who may occasionally dealwith these diseases.

Vinidh PaleriJohn Hill

Medicine is an ever changing speciality, as is medicaleducation. Recent changes in medical education have meantless exposure to some clinical specialities, withOtorhinolaryngology being one of them. Infections form asignificant proportion of ENT diseases, more so in primarypractice and emergency care. The aim of this book is toprovide a richly illustrated overview of ENT infections,taking the reader through clinical presentation, diagnosisand management, along with supporting chapters onmicrobiology and pharmacology. The illustrations havebeen carefully chosen to represent common findings,

Acknowledgements

The authors are very grateful to all medical and nursingstaff, past and present, in the Department ofOtolaryngology-Head and Neck Surgery in Newcastle uponTyne Hospitals. We thank them for their help in procuring

the vast majority of illustrations in this book. We areindebted to Professor Janet Wilson for her valuable adviceand help during the preparation of this book.

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ix

Contributors

Surianarayanan Gopalakrishnan, MS, DLOProfessor and HeadOtolaryngology – Head and Neck SurgeryJawaharlal Institute of Postgraduate Medical Education

and ResearchPondicherry, India

John Hill, FRCS Eng, FRCS Ed, FCS HKConsultant Surgeon and Honary Senior LecturerOtolaryngology – Head and Neck SurgeryNewcastle-upon-Tyne Hospitals NHS Foundation TrustNewcastle-upon-Tyne, UK

Wolfgang Issing, MDConsultant Surgeon Otolaryngology – Head and Neck SurgeryNewcastle-upon-Tyne Hospitals NHS Foundation TrustNewcastle-upon-Tyne, UK

Andreas Leunig, MDConsultant SurgeonOtolaryngology – Head and Neck SurgeryKlinikum GroßhadernLudwig-Maximilians UniversityMunich, Germany

Manjusha Narayanan, MD, FRCPathConsultant MicrobiologistDepartment of MicrobiologyNewcastle-upon-Tyne Hospitals NHS Foundation TrustNewcastle-upon-Tyne, UK

Vinidh Paleri, MS, FRCS Eng (ORL-HNS)Consultant Surgeon and Honorary Senior LecturerOtolaryngology – Head and Neck SurgeryNewcastle-upon-Tyne Hospitals NHS Foundation TrustNewcastle-upon-Tyne, UK

Konrad S Staines, BChD, FDSRCS (Eng), MOMed RCS (Edin)

Consultant in Oral MedicineNewcastle Dental Hospital & SchoolNewcastle-upon-Tyne Hospitals NHS Foundation TrustNewcastle-upon-Tyne, UK

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x

Abbreviations

AIDS acquired immunodeficiency syndromeBIPP bismuth iodoform paraffin pasteCLED cystine lactose electrolyte deficient (medium)CMV cytomegalovirusCT computed tomographyDNA deoxyribonucleic acidEBV Epstein–Barr virusENT ear, nose, and throatESR erythrocyte sedimentation rateGABHS group A beta haemolytic streptococciGAS group A streptococciHHV human herpes virusHIV human immunodeficiency virusHL hairy leukoplakiaHPV human papilloma virus

HSV herpes simplex virusIFA immunofluorescent assayIg(M) immunoglobulin(M)MIC minimum inhibitory concentrationMMR mumps, measles, and rubellaMR(I) magnetic resonance (imaging)MRSA methicillin-resistant Staphylococcus aureusOME otitis media with effusionPCR polymerase chain reactionRBC red blood cellRNA ribonucleic acidRSV respiratory syncytial virusTEM transmission electron micrographVZV Varicella-zoster virus

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Clinical examination

EarJohn Hill

Chapter 1

Examination of the ear

In infective cases it is worth checking behind the ear to seeif there is any swelling of the post-auricular lymph nodes ora subperiosteal abscess (1.1; see acute mastoiditis,4.32–4.34). The best view of the drum is obtained by usingan auriscope which is inserted into the lateral third of the earcanal only (1.2). Avoid putting the tip of the speculum intothe medial two-thirds of the canal as it is much moresensitive. The view is improved by elevating the pinnaupwards and backwards in an adult or straight backwards in

a child. Holding the auriscope horizontally, rather thanvertically, means the patient’s shoulder is less likely to get inthe way. Holding the little finger out extended towards thecheek is a useful technique in children because if the childturns towards the examiner unexpectedly it reduces thechance of twisting the speculum of the auriscope in the earcanal, which can be painful. If the drum is difficult to see itis often worth looking more superiorly by tilting the patient’shead away from the examiner (1.3).

1

1.1 Normal pinna showing the main anatomical features:

helical fold (1), triangular fossa (2), antihelical fold (3),

scaphoid fossa (4), lobule (5), tragus (6), and conchal

bowl (7).

12

3

4

5

67

1

2

3

4

5

1.2 Normal right tympanic membrane showing the main

features: umbo (1), handle of the malleus (2), pars

flaccida (3), long process of the incus visible through the

pars tensa (4), and bulge of the anterior wall of the ear

canal (5).

ENT Final.qxd:Dementia final.qxd 12/2/10 06:24 Page 1

Tuning fork testsThe traditional Rinne and Weber tuning fork tests using a512 Hz tuning fork are still of value in establishing whetherhearing loss is conductive or sensorineural in nature.Hearing loss due to disease in the external ear canal ormiddle ear will give a conductive loss. Diseases affecting theinner ear cause a sensorineural loss.

Rinne testThe tuning fork is placed on the mastoid process behind theear and counter pressure applied to the side of the head tomake sure of good contact. The patient is asked: (1) Canyou hear the tuning fork? The tuning fork is then heldalongside the ear approximately 2–3 cm from the meatusand the patient is asked: (2) Is this louder or quieter (1.4,1.5)? A positive Rinne response means that the tuning forkwas heard louder beside the ear rather than placed on themastoid behind. A negative Rinne response is the converse.

Clinical examination2

Weber testThe tuning fork is placed in the centre of the patient’sforehead. The patient is asked: (1) Can you hear the tuningfork? (2) Is it louder in one ear or is it equally heard in bothears (1.6)?

InterpretationA Rinne positive response is present if the hearing is eithernormal or the hearing loss is sensorineural in nature. If theRinne test is negative, hearing loss will be due to aconductive loss. If a conductive hearing loss is present, aWeber test should be loudest in the affected ear. Ifsensorineural hearing loss is present a Weber test should beheard loudest in the unaffected ear.

1.4 Rinne test 1. ‘Can you hear this?’1.3 Position of auriscope during otoscopy.

1.5 Rinne test 2. ‘Is this louder or quieter?’ 1.6 Weber test. ‘Does this sound as if the sound is in the

middle or coming from the side? Which side?’


Clinical examination 3

NoseWolfgang Issing

Examination of the nose

Traditional anterior rhinoscopy using Thudicum’sspeculum and a headlight or head mirror is helpful indetecting gross anatomical variations such as septaldeviation, dislocation of the collumella (1.7) andhypertrophic inferior turbinates. With the help of a rigid(1.8) or flexible endoscope, the whole of the nasal cavity andthe postnasal space can be examined. The middle meatus,into which most of the sinuses drain, can be thoroughlyexamined (1.9) and bony crests, spurs (1.10) and otherabnormalities farther back in the nasal cavity can beidentified. Rigid endoscopes give the clearest view butflexible endoscopes help if the nasal anatomy does not allowpassage of the rigid endoscope. Decongestion of the nose,using sprays containing pseudo-ephedrine or pseudo-ephedrine plus lignocaine may be necessary to achieveoptimum results and improve tolerance. The examinationshould be done to document findings systematically in theinferior and the middle meatus and the spheno-ethmoidalrecess. Several anatomic variations exist in the nasal cavitythat may contribute to an infection (1.11, 1.12). Possiblefindings include the presence of mucus or mucopus, polyps,and other mass lesions. Except for the posterior ethmoidand the sphenoid sinuses, all the sinuses drain into themiddle meatus. Thus, the majority of sinus infectionspresent with signs in the middle meatus.

Radiological examination

If indicated, a CT scan of the paranasal sinuses in a coronalsequence is the most appropriate examination technique(1.13). Plain X-rays do not have a role in managing sinusinfections.

1.7 Dislocation of

the columella into

the left nostril.

1.8 Rigid nasal endoscopy can be easily performed under

local anaesthesia.

1.9 Left middle meatus.



1.10 Septal spur in contact with the right inferior turbinate. 1.11 Septal spur protruding into the left middle meatus

which impairs drainage of the sinuses.

1.12 Right middle meatus with uncinate process and bulla

ethmoidalis. The latter can impair sinus drainage.

1.13 Coronal CT scan of paranasal sinuses demonstrating

well aerated sinuses and a pneumatized middle turbinate.



1.15

Inspection of

the oral cavity

with a good

head light is

essential to

identify subtle

mucosal

lesions.

Buccal mucosa

Oral tongue

Lips

Floor ofmouth

Dentition

Oral cavity, oropharynx, larynx,hypopharynx, and neckVinidh Paleri

Examination of the oral cavity

A good headlight and proper positioning is essential toexamine the oral cavity and the oropharynx. The examinerand the patient sit with their legs close together, but facingopposite directions. This is demonstrated in figure 1.14.The oral cavity starts at the lips and is separated from theoropharynx behind by an imaginary plane that runs from thejunction of the hard and soft palate above to thecircumvallate line on the tongue below. It comprises ofseven regions: these include the vermilion margin of the lips,the buccal mucosa, the gingiva and the teeth of the upperand lower jaws, the floor of the mouth, the hard palate, theoral tongue and the retromolar trigone (1.15–1.17). Theretromolar trigone is that part of the mucosa that lies over

the ascending ramus of the mandible behind the last molarand heads up to the maxillary tuberosity (1.18).

Systematically counting off all these regions will ensurethat that all the mucosal lining is inspected duringexamination, especially the recesses where findings can bemisssed. Oral cavity examination is best achieved with agood headlight and a pair of angled tongue depressors.These can be used to sweep the buccal mucosa gently awayfrom the gingiva so as to inspect the gingivo-buccal sulcicomprehensively. The parotid duct orifice (Stenson’s duct)is also inspected during this phase of the examination, seenopposite the crown of the second molar (1.19). Thismanoeuvre is once again useful to inspect the posterior most

1.14 Optimal positioning for ENT examination. Note how

the examiner’s and the patient’s legs face opposite

directions.



1.16 The hard palate. 1.17 The floor of the mouth.

corner of the floor of the mouth where findings can bemissed. The status of the submandibular duct orifice(Wharton’s duct) is noted while inspecting the floor of themouth (1.17). Examination findings should note the colourof the oral mucosa and the presence of discrete lesions. Ifpresent, their site, number, size, and colour (usually white orred) are noted. If white patches are seen one should assess ifthey can be gently rubbed off with a tongue blade. If they dorub off, the base underneath the patches should be inspectedfor erythema and bleeding. Patches caused by pseudomembranous type of Candida infection tend to rub off

1.18 Left retromolar trigone seen just behind the last

molar.This region overlies the ascending ramus of the

mandible.

without any underlying bleeding. Leukoplakic patchescaused due to an inciting factor do not rub off. Lesions mayalso be vesicular or ulcerated, and flat or proliferative,sometimes with surface bleeding.

The salivary gland ducts should be assessed for the natureof the secretions and for redness around the ducts.Documentation should also include the dentition and thepresence of carious teeth if any. Where appropriate, dentalpercussion should be performed to identify tenderness orlack of sensation in teeth.

1.19 The parotid duct orifice (Stenson’s) opposite the

crown of the second molar tooth is being demostrated by

the pointer.

Ventral surfaceof tongue

Frenulum

Submandibularduct orifice


Examination of the oropharynx

The oropharynx comprises of four regions and five walls,akin to a box lying open on its side, facing the examiner. Thetonsils and the lateral pharyngeal walls on either side formthe lateral walls. The posterior pharyngeal wall lyingbetween the level of the soft palate and the hyoid bone formsthe posterior wall, the soft palate forms the roof, and theposterior one-third of the tongue behind the cicumvallateline forms the floor. Except for the base of the tongue, all theother regions can be quite easily assessed on a simpleinspection by gently depressing the tongue using a tonguedepressor (1.20). When performing this manoeuvre careshould be taken not to insert the tongue depressor beyondthe anterior two-thirds of the tongue as this can trigger a gagreflex.

Findings on the mucosa are inspected as above.Infections of the oropharynx can also cause tonsillarhypertrophy and exudates on the surface. The tongue baseis visualized better on a flexible nasendoscopy or an indirectlaryngoscopy using a mirror. It must be noted that apartfrom mucosal lesions, many tongue base neoplasms tend tostart submucosally and these are better felt than seen.Therefore, a complete oropharyngeal examination mustinclude tongue base palpation. However, this may not beappropriate in most clinical scenarios where an infection issuspected, especially in the child presenting with an acutesore throat.


Examination of the larynx andhypopharynx

Examination of larynx and hypopharynx is best performedusing a flexible nasolaryngoscope (1.21). In the past,examination was commonly performed using a mirror andthis can be a useful technique especially in patients who areunable to tolerate a nasolaryngoscopic examination. Thetechnique of nasolaryngoscopy is discussed elsewhere in thisbook. Following introduction of the flexible naso laryngo -scope and the examination of the nasopharynx, the patientis asked to breathe through the nose. This enables the softpalate to fall forwards. At the same time the tip of the scopeis turned downwards. This gives a panoramic view of theposterior oropharynx, the hypopharynx, and the larynx.

The endoscope is advanced further and inspection of thetongue base and vallecula is performed by asking the patientto open his or her mouth wide and protrude the tongue.Following this manoeuvre the regions of the larynx aresystematically inspected: the epiglottis, aryepliglottic folds,the arytenoids, the false cords, and the true cords (1.22).The true cord mobility is also assessed. Hypopharyngealregions are the posterior pharyngeal wall below the level ofthe hyoid bone to the cricopharynx, the pyriform fossae onboth sides, and the postcricoid region. The pyriform fossaeare best inspected during phonation, as medial movement ofthe cords causes the fossae to open (1.23). Instructing thepatient to perform a Valsalva manoeuvre during flexible

1.20 Oropharynx

can be examined

easily by gently

depressing the

tongue. Note that

the tongue base

cannot be

examined by

mere inspection

alone.

1.21 Flexible nasolaryngoscope being used to assess the

larynx and the hypopharynx.



endoscopy also opens the pyriform fossae. Findings to lookfor include a redness or erythema of the mucosa, the colourof the vocal cords, the presence of oedema, swelling orulceration or growths anywhere in the larynx or thehypopharynx. It must be noted that the post cricoid regionis not so easy to see and lesions in this part of thehypopharynx can be missed with this examination.

Examination of the neck

The examination is primarily directed at detectinglymphadenopathy and will pick up other lumps in the neckduring the course of the examination if systematicallyperformed. The neck nodes can be divided into a superficialand deep group. The superficial nodes are placed like a ringbetween the junction of the head and neck and include thesubmental, facial, pre-auricular, post-auricular, and theoccipital nodes. The deep nodes are distributed around themajor structures and are located as follows: submandibular,upper, middle and lower jugular, supraclavicular, and theposterior triangle.

Examination of the neck is best done with the examinerstanding behind the patient. The author prefers to examineone side at a time. This enables one to document findings

1.22 View of the larynx during inspiration using a 70° rigid

endoscope, showing abducted cords.

1.23 View of the larynx during phonation using a 70° rigid

endoscope, showing adducted cords.

accurately, which include the site, size, consistency, andmobility of any lumps. The patient’s neck is tilted andturned to the side where the examination is to be performed(1.24). This will relax the sternomastoid muscle and enablegood palpation of the jugular chain of nodes. Subtleenlargement of the jugular nodes can be missed if themuscle is not relaxed.

The examination starts in the submandibular region fromthe front to the angle of the mandible. The soft tissues arerolled against the mandible to feel for nodes. The jugularchain is examined by gently pinching up the sternomastoidmuscle from superior to inferior and feeling for nodesunderneath the muscle. Once the clavicle is reached, thesupraclavicular region is examined, heading towards theacromion. This naturally leads to the inferior part of thetrapezius muscle. Climbing up the trapezius will take oneback to the mastoid and the upper end of the sternomastoidmuscle (1.25). The thyroid gland is then palpated in themidline, asking the patient to swallow. Any enlargement willbe felt to move under the finger tips.

The superficial nodes are then assessed. The submentalnodes are palpated by pressing the soft tissues against themandible. The facial and the pre-auricular nodes lie on themandible and the post-auricular nodes on the mastoid. Theoccipital nodes are to be found in the nape of the neck.

Aryepiglotticfold

Truecord

Falsecord

Arytenoid

Pyriform sinus



1.24 The neck is turned and tilted to the same side that is

being examined to relax the sternomastoid muscle.

1.25 A suggested method to examine systematically the

deep lymph nodal chains in the neck.


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