Sudden, painful, unilateral salivary gland swelling (sialadenopathy)

is due to a stone obstructing the duct (sialolithiasis). Other

causes of enlarged salivary glands are mumps (usually bilateral),

sarcoidosis, human immunodeficiency virus-related cysts, bacterial

infection (suppurative parotitis; Fig. 9.24) and cancer. The clinical

features of important neck lumps are summarised in Box 9.10.

9.9 Causes and features of dysphonia

Causes Features

Neonate

Congenital abnormality Laryngomalacia most frequent cause

More common in preterm neonates

Associated stridor due to immature

larynx folding in on inspiration

Neurological disorder Examples include vocal cord palsy

Unilateral causing weak, breathy cry

Bilateral may cause stridor and airway

obstruction

Child

Infection:

Croup

(laryngotracheobronchitis)

Barking cough, stridor, hoarse voice

Laryngitis Bacterial or viral

Voice abuse (screamer’s

nodules)

History of voice abuse

Adult

Infection:

Upper respiratory tract

infection

Laryngitis

Associated features of upper

respiratory tract infection

Trauma Mechanical or chemical injury

Cigarette smoking

Gastro-oesophageal reflux disease

(reflux laryngitis)

Lung cancer Vocal cord paralysis, breathy voice

Vocal cord nodules (singer’s

nodules)

Prolonged vocal strain

Rough voice

Reduced vocal range

Vocal fatigue

Neurological disorder Weak, wet or dysarthric voice

Cancer of the larynx Rough voice, constant, progressive,

often affects smokers

Associated with dysphagia,

odynophagia, otalgia

Functional cause

Fig. 9.24 Pus discharging from the parotid duct.

188 • The ear, nose and throat

9.10 Causes and features of neck lumps

Location in neck Diagnosis Clinical features

Midline Thyroglossal cyst Smooth, round, cystic lump that moves when patient sticks out

tongue

Submental lymph nodes Associated infection of lower lip, floor of mouth, tip of tongue or

cheek skin

Thyroid isthmus swelling Lump moves on swallowing

Dermoid cyst Small, non-tender, mobile subcutaneous lump

Lateral

Anterior triangle Thyroid lobe swellings:

Simple, physiological goitre

Multinodular goitre

Solitary nodule

Thyroid tumours: benign (adenoma) and malignant

(papillary, follicular, medullary, anaplastic)

Lump moves with swallowing but not on tongue protrusion

Submandibular gland swelling:

Infection, stones, autoimmune disease

Benign or malignant tumours

Swelling below the angle of the mandible. Can be felt bimanually.

Involvement of more than one gland suggests a systemic condition.

A lump within the gland suggests a tumour. Uniform enlargement

with pain suggests infection or stones

Parotid gland swelling:

Mumps, parotitis, stones, autoimmune disease

Swelling in the preauricular area or just below the ear

Parotid gland mass:

Benign

Malignant tumours

Hard, fixed mass with facial nerve weakness suggests a malignant

tumour of the parotid gland

Branchial cyst Smooth, non-tender, fluctuant mass. Not translucent. Slowly

enlarging, may increase after upper respiratory tract infection

Lymph nodes:

Malignant: lymphoma, metastatic cancer Large, hard, fixed, matted, painless mass suggests malignancy

Infection: bacterial infection of head and neck,

viral infection (e.g. infectious mononucleosis),

human immunodeficiency virus, tuberculosis

Lymph nodes can be reactive to infection and are usually smooth,

firm, mobile and tender

Posterior triangle Lymph nodes:

Malignant

Benign

See p. 32

Carotid body tumour Firm, rubbery, pulsatile neck mass, fixed vertically due to attachment

to bifurcation of common carotid. A bruit may be present

Carotid artery aneurysm Rare, present as pulsatile neck mass

Cystic hygroma Soft, fluctuant, compressible and transilluminable mass, usually seen

in children

Cervical rib Hard, bony mass

Supraclavicular fossa Supraclavicular lymphadenopathy Left supraclavicular (Virchow’s) node may suggest gastric

malignancy

Fig. 9.25 Torus palatinus. This benign asymptomatic central palatal bony

mass is more common in Asian populations. From Scully C. Oral and

Maxillofacial Medicine. 2nd edn. Edinburgh: Churchill Livingstone; 2008.

• Inspect the tonsils, noting size, symmetry, colour and any

pus or membrane.

• Touch the posterior pharyngeal wall gently with the tongue

depressor to stimulate the gag reflex. Check for

symmetrical movement of the soft palate.

Palpation

• If any lesion is seen in the mouth or salivary glands,

palpate it (wearing gloves) with one hand outside on the

patient’s cheek or jaw and a finger of your other hand

inside the mouth (bimanual palpation).

• Feel the lesion and identify its characteristics (p. 32).

• If the base of the tongue or the tonsils are asymmetrical,

palpate it using a gloved finger.

• If the parotid gland is enlarged or abnormal on inspection,

examine the facial nerve and check if the deep lobe (tonsil

area) is displaced medially.

• Palpate the parotid and submandibular duct, feeling for

stones.

• Palpate the cervical lymph nodes (p. 33).

The physical examination • 189

9

biopsy (Fig. 9.27B). Cancers (usually squamous) may occur at

any site in the mouth. Any painless persistent mass in the mouth

should be assumed to be oral cancer and referred urgently for

biopsy. Similarly, any mouth ulcer persisting for over 3 weeks

requires biopsy to exclude cancer (Fig. 9.27C).

A stone may be felt in the submandibular (or, rarely, the parotid)

duct. Rotten teeth (dental caries) are common in patients with

poor oral hygiene (Fig. 9.27D).

Neck

The neck must be examined in all patients with mouth or throat

symptoms, or a neck mass.

Examination sequence

• With the patient sitting down and their neck fully exposed

(ties and scarves removed and shirt unbuttoned), look at

their neck from in front. Inspect for scars, masses or

pulsation.

• From behind, palpate the neck. Work systematically

around the neck. Start in the midline and gently palpate

the submental, submandibular and preauricular areas,

assessing for the presence of any masses or swelling.

Then palpate down the anterior border of the

sternocleidomastoid muscle to the midline inferiorly.

• Palpate the midline structures of the neck from inferior to

superior up to the submental area, noting any masses.

• If a midline mass is present, ask the patient to swallow

(offer a glass of water if needed) and then instruct them to

stick out their tongue while you palpate the mass.

Movement superiorly on swallowing suggests a thyroid

Cracking of the lips can be the result of cold exposure (‘chapped

lips’), riboflavin deficiency, chronic atrophic candidiasis or iron

deficiency (Fig. 9.26). Squamous and basal cell cancers occur

on the lips and are associated with smoking and sun exposure.

The normal tongue appearance includes areas of smooth

mucosa (‘geographic tongue’) or, conversely, excessive furring.

A smooth red tongue with diffuse papillary atrophy occurs in

iron or vitamin B12 deficiency. Tongue protrusion may be limited

by neurological disease, painful mouth or a tight frenulum.

Macroglossia (enlarged tongue) occurs in Down’s syndrome,

acromegaly (see Fig. 10.9), hypothyroidism and amyloidosis.

Wasting and fasciculation of the tongue are features of motor

neurone disease.

White plaques of candidiasis on the tongue or mucosa (Fig.

9.27A) come away easily when scraped but leukoplakia (a

keratotic precancerous condition) does not and requires excision

Fig. 9.26 Angular stomatitis.

$

%

& '

Fig. 9.27 Disorders of the tongue and teeth. A Oral thrush. B Leukoplakia. C Aphthous stomatitis causing a deep ulcer in a patient with

inflammatory bowel disease. D Dental caries. (B) From Bull TR. Color Atlas of ENT Diagnosis. 3rd edn. London: Mosby–Wolfe; 1995.

190 • The ear, nose and throat

swelling (p. 194), while movement on tongue protrusion

suggests a thyroglossal cyst (Fig. 9.28).

• Palpate the posterior triangle of the neck, including the

posterior border of sternocleidomastoid and anterior

border of trapezius. Palpate for occipital lymph nodes

posteriorly.

• For any mass, note the size, site, consistency, edge,

fixation to deeper structures, tethering to the skin, warmth,

fluctuance, pulsatility and transillumination (p. 32).

Investigations

Initial investigations are summarised in Box 9.11.

9.11 Mouth, throat and neck investigations

Investigation Indication/comment

Full blood count Infective causes of mouth, throat or

neck symptoms

Monospot Infectious mononucleosis

Hepatosplenomegaly can occur in

infectious mononucleosis so liver

function tests can be useful

Throat swab Acute tonsillitis and pharyngitis

Patients may carry Streptococcus

pyogenes and have a viral infection

(detected by PCR), so swab does not

always help direct management

PCR may help identify viral causes

Endoscopy and biopsy Cancer of larynx and pharynx, changes

in vocal cords

Under general anaesthetic

Ultrasound ± fine-needle

aspiration