Neck (excluded here; incl. in Endocrine)
Main complaints in H&N:
Lump/ swelling/ mass
- Mass = lesion (abnormal)
- Site, size, shape, surface, consistency, border, temperature, fixed to over/ underlying structure, colour-change overlying mass, tender
Ulcer/ growth in the mucosal lining of the oral cavity or oropharynx
- Ulcer = discontinuation of epithelium
- Site; Size
- Edge: irregular, regular, raised/ elevated (Irregular, raised -> malignant edge = where tumour advances/ invading; Benign: regular advancement; punched out = TB)
- Base (benign: overlying greyish epithelium growing on top of pinkish granulation tissue; malignant: dirty base, covered by slough)
- White/ yellow base = non-healing (lack of BV)
- [Mass, ulcer -> 70% of H&N Pt's]
Tumour
- Mass due to neoplasia (lesion due to increased mitosis)
- Benign (no indication to invade or metastasise) or malignant (metastasis into blood or lymphatics, direct invasion)
- Long time ago: any mass was called a tumour
Pain
- Diffuse: left side of face (eg. Headache due to skull-based tumour)
- Localised: eg. 3rd molar
- Site
- Features: burning, throbbing, sharp, dull
- Radiation
- Aggravating/ relieving factors
- Progress: cyclical, constant
Discharge or bleeding from the nose, ear(s), skin surface (e.g. a fistula)
- Abnormal discharge (normally no discharge from that orifice)
- Normal discharge in excessive quantities
- Discharge: purulent, clear/ serous, blood-stained
- Bleeding = frank bleeding, not blood-stained discharge
- NPC: post-nasal drip > epistaxis
- Haemoptysis; cough up blood
- Haematemesis: vomit up blood
Deafness
Difficulty in swallowing (dysphagia)
- Revise process of swallowing (starts at oral cavity)
- May be lesion in oral cavity/ oral pharynx causing difficulty swallowing (painful) - eg. Ca tongue, oral cavity, oropharynx (localised)
- Dysphagia: usu. means mechanical obstruction (but also functional probs)
- HK Chinese: dysphagia highly suspicious of ca oeso (painless progressive dysphagia for few mths) (painless: sympathetic innervation; no somatic)
Difficulty in breathing
- Aw/ RS obstruction
- Lower aw: distal to main bronchus (medical - eg. COPD, asthma -> wheezing, dyspnoea - SOB)
- Upper aw: trachea and upwards (mechanical - eg. Foreign body, swelling or paralysis of vocal cords)
- Glottis (laryngeal inlet): narrowest part of upper aw, guarded by vocal cords (therefore, swelling of vocal cord by swelling or oedema -> stridor)
Hoarseness or a change of voice
- Larynx (control by brain, n supply, vocal cords properties)
- Eg. Stroke: nervous control problem, change in char of voice, cannot vocalise
- Recurrent laryngeal n -> control larynx (unilateral paralysis: if other side can compensate, no change in char of voice - therefore depends on whether compensation occurs or not)
- Bilateral vocal paralysis: flaccid (no obstruction), partially flaccid (abductor loss function, adductor retain function, partially paralysed cord in midline) -> if tightly closed - asphyxiation; slight gap - stridor
- Polyps (voice abuse - eg. Mothers, hawkers), polyps prevent proper closure of vocal cords, most common reason of hoarseness)
- Ca larynx: supra, glottic, infra-glottic tumour (glottic tumour right on cord, therefore cause hoarseness, infra and supra-glottic tumours don't usually cause hoarseness)
Ear symptoms (tinnitus, deafness, vertigo)
Asymmetry/ abnormal facies
- Position of normal structures abnormal
- Deficiency/ excess of normal structure
- Additional/ missing structures
- Soft tissue: skin cover, facial m's (facial n innervation)
- Hard tissue: bone (frontal, orbit, cheek, nasal, maxilla, mandible)
If suspect thyroid: additional Q's - hyper- or hypothyroid?
Eg. Palpitations, heat intolerance, tremor and weight loss with a normal appetite.
You will then ask the routine questions about the main complaint (site, duration, changes in size/colour etc.)
DIAG: regions behind face: NC, NP, OC, OP, HP
- NC: behind nose, above hard palate
- OC: seen when you look into mouth, in front of junction of hard-soft palate, holds anterior 2/3 tongue
- HP aka laryngopharynx
- Venting tube (like on ferry) similar to pharynx; like face mask applied from back (onto NC + OC)
- vertical line: through junction of hard palate and soft palate; cuts tongue into anterior 2/3 and posterior 1/3
- 1st horizontal line: through junction of hard palate and soft palate
- 2nd horizontal line: through epiglottis
- 3rd horizontal line: through junction of hypopharynx + oeso (upper oeso sphincter; cricopharyngeus muscle, marked by lower border of cricoid bone)
DIAG: coronal cut through oral cavity
- U-shaped structure = floor of mouth (covered by ventral surface of tongue)
- Buccal cavity: inner surface lined by buccal mucosa, need to push away cheek to see sulci (spatula)
DIAG: coronal cut through oropharynx
- Looking behind junction of hard and soft palate
- Tonsils: adjacent to lateral pharyngeal wall
- Post pharyngeal - look here for pharyngitis
- Soft palate = oral pharyngeal structure (therefore, don't say you can see tumour on oral cavity on soft palate)