PHYSICAL SIGNS OF THE NECK Triangles of

PHYSICAL SIGNS OF THE NECK

Triangles of the neck The neck is divided by the sternomastoid muscles into: anterior and posterior triangles.

Anterior triangle of the neck The anterior triangle is bounded: laterally by the SCM muscle, medially by the midline, superiorly by the mandible.

Posterior triangle of the neck The posterior triangle is bounded: posteriorly by the trapezius muscle, anteriorly by the SCM. muscle inferiorly by the clavicle.

Triangles of the neck Anterior triangle muscular triangle--formed by the midline, superior belly of the omohyoid, and SCM carotid triangle--formed by the superior belly of the omohyoid, SCM, and posterior belly of the digastric submental triangle--formed by the anterior belly of the digastric, hyoid, and midline submandibular triangle--formed by the mandible, posterior belly of the digastric, and anterior belly of the digastric Posterior triangle supraclavicular triangle--formed by the inferior belly of the omohyoid, clavicle, and SCM occipital triangle--formed by inferior belly of the omohyoid, trapezius, and SCM

Triangles of the neck Anterior triangle of the neck thyroid isthmus Posterior triangle of the neck Spinal accessory nerve Brachial plexus Subclavian artery-third part External jugular vein Parotid gland

Anterior aspect of the neck • • • Body of the hyoid bone Thyrohyoid membrane Upper border of the thyroid cartilage Cricothyroid ligament Cricoid cartilage Cricotraheal ligament First ring of the trachea Isthmus of the thyroid gland Suprasternal notch

Anterior triangle of the neck

Surface landmarks

Anterior triangle of the neck

Carotid sheath • Carotid artery • Internal jugular vein • Vagus nerve • Deep cervical lymph nodes Marked out by a line joining the sterno-clavicular joint to a point midway between the tip of the mastoid process and the angle of the mandible. At the upper border of the thyroid cartilage, CCA bifurcates into the internal and external branches. The pulsations can be felt at this level.

Carotid sheath- common carotid artery, internal jugular vein, vagus nerve with its superior laryngeal branch

Common carotid artery: external carotid artery, internal carotid artery Branches of ECA: superior thyroid artery , superior laryngeal artery, lingual artery, facial artery.

Lumps in the neck

Lumps in the neck 1. Lymph nodes- lymphadenopathies: Infections Metastatic tumors Primary tumors 2. Tumors- cystic or solid 3. Thyroid gland- Goiter- diffuse or nodular

Lymphadenopathies

LYMPH NODES

LYMPH NODES

NECK EXAMINATION

THYROID NODULE

Case report An 8 -year-old girl, Address: country side of Chiang Mai province CC : Fever for 10 days and sore throat for 6 days History > 10 days , she had an acute onset of high-graded fever. She took paracetamol but the fever and headache remained. Patient was seen by a doctor who gave a diagnosis of acute tonsillitis (injected and enlarged tonsils, body temperature 40 C, CBC: Hb 11. 0 gm%, HCt 34%, WBC 4, 600/cu. mm, N 68%, B 1%, L 29%, platelets 177, 000/cu. mm).

Case report She was given intramuscular lincomycin 450 mg and oral amoxycillin 250 mg 3 times a day. High intermittent fever persisted. > 2 days, she developed rashes over the trunk, arms, and thighs. She also had various nonspecific symptoms, including faintings, mild nausea, periumbilical abdominal pain, diarrhea, mild sore throat, nonproductive cough, and severe bitemporal headache. On admission day, the fever persisted and her sore throat got worse

Case report Past History: The girl had history of cleft lip and cleft palate which were repaired since she was 3 months old. Her immunization status was up to date. There was no family history of similar illness. She usually plays around her house where grass and tree wildly grow on humid ground.

Physical examination VS: T 39. 5 C, pulse rate 108/min, RR 24/minm, BP=100/60 mm. Hg. , BW 20 Kg GA: looked sick, but fully concious Skin: faint maculopapular rashes were observed over arms and thighs. An ulcer with black crust on erythematous base was seen over her right shoulder region. Its size was approximately 8. 0 mm in diameter. The lesion was not tender.

Lymphadenopathy Multiple enlarged lymph nodes were palpated as follows: 2 large: 1, 3 and 1, 2 cm. in diameter on right supraclavicular triangle Multiple small lymph. nodes<5 mm. in diameter in chain along both sides of posterior triangle All nodes were soft, not-tender, movable and smooth surface

Case report ENT examination revealed enlarged tonsils grade III/IV with hyperemia which extended on anterior tonsillar pillars and soft palate were detected. There was no exudative patch. Her pharynx was not injected. Her conjunctiva was normal. Chest: Heart sound: WNL, Lungs: no adventitious sound Abdomen: palpable liver (4 cm below right costal margin, span 13 cm. ), spleen was not palpable NS: WNL

Enlarged tonsils with hyperemic soft palate

Maculopapular rash

A black crusted ulcer- right shoulder

Cervical lymphadenopathies

Case report Active Problem list: 1. Prolonged fever for 10 days 2. Nonspecific systemic complaints: faintings, nausea, abdominal pain, diarrhea, sore throat, cough, headache, poor appetite 3. Generalized maculopapular rash 4. Cervical and supraclavicular lymphadenopathy 5. Injected and enlarged tonsils with hyperemic soft palate 6. A black crusted ulcer at the right shoulder 7. Hepatomegaly

Case report Initial laboratory investigations: CBC: Hb 9. 2 g/dl, Hct 28 %, WBC=5, 200/cu. mm (N 80%, L 20%), platelets 131, 000/cu. mm Peripheral blood smear for malarial pigment: negative U/A: WNL

Case report Provisional diagnosis of "scrub typhus" was made, and therapeutic diagnosis was started with oral doxycycline 2. 2 mg/kg/dose given every 12 hrs (for the first 2 doses). The fever dramatically subsided. Twelve hours later, she became more cheerful and her appetite returned. Therefore, doxycycline (2. 2 mg/kg/day div q 12 hrs) was continued. The hyperemic soft palate and tonsils subsequently faded off. The tonsils were slightly decreased in size 36 hours after doxycycline. The lymph nodes and liver remained palpable at the time of the discharge from the hospital on day 3 of the treatment. Doxycycline was continued for 14 days.

Temperature chart

Case report Follow-up: Seven days after the discharge (10 days after doxycycline) she was followed up. She was afebrile and had no rash. The lesion (eschar) moderately reduced in size. Her tonsils and lymph nodes became normal size for age. Liver was just palpable below right costal margin.

Discussion Scrub typhus is a febrile illness caused by Orientia tsutsugamushi, an obligate intracellular bacterium in the Rickettsiaceae family. The organism is transmitted during the bite of chigger. Scrub typhus is confined to a definite geographic region. It extends from northern Japan and far eastern Russia in the north, to northern Australia in the south, and to Pakistan and Afghanistan in the west. Tests for anti-O. tsutsugamushi antibody are available in only a few medical centers in Thailand

Case report Eschar occurs as the result of mite (chigger) bite. Since the chigger is small (<5 mm) and the bite is neither painful nor itchy, the history of the bite was not usually obtained. The mite lives in bushes.

Case report 2 Patient: A 9 -year-old HIV-infected girl Address: Payoa province (Northern Thailand) CC: Pain at both eyes for 4 weeks. Fever for 3 weeks. Present Illness: 4 weeks PTA, after coming back from swimming in a river, she started having pain at her both eyes (more on the left side). The pain later accompanied with tearing, yellowish discharge and photophobia. The eye drop medicine from the local hospital could not relief her eye pain. 3 weeks PTA, she developed moderate grade fever and mild dry cough. Her eye pain persisted. She lost her appetite and was admitted to a hospital where she received ceftriaxone 70 MKD, and ampicillin for 1 week without improvement.

Case report 1 week PTA, all symptoms persisted and she started having abdominal pain. Past medical history: At the age of 3 years she was diagnosed as having HIV infection. Her mother has a history of pulmonary tuberculosis and has been on treatment for 7 -8 months. She has not gained weight for 1 year.

Case report Physical examination: GA: febrile, thin and fatigue. BW=18 kg Vital signs: T: 40 celcius, RR: 36/min, PR: 122/min, BP: 110/72 mm. Hg EYES; pale and injected conjuctivae, left corneal ulcer and photophobia. Oral cavity; whitish patches (thrush) Ears; intact both tympanic membranes Lymph nodes: Right supraclavicular lymphnode enlagement: 2 cm in diameter, firm, not tender

Case report Heart: Tachycardia, no murmur Lungs: Medium creppitation both lungs Abdomen: Distension, generalized mild tender, liver 4 cm below RCM, Extremities: no clubbing of fingers Skin: hypo- and hyperpigmentation scars at extremities. Neurological examination: no meningial sign, no neurological deficit

Supraclavicular lymphnode

Corneal ulcer

Case report Problem list: 1. HIV-infected child with prolonged fever 2. Corneal ulcers

Case report Laboratory investigations: CBC: Hb 6. 1 g/dl, Hct 18%, WBC 3, 600/mm 3 (N=74%, L=22%, M=16%) CD 4 T-cell count: 4% (20 cells/mm 3) Tuberculin skin test : Negative CXR: Cardiomegaly, generalized reticulo-nodular infiltration both lungs suggesting miliary tuberculosis. Echocardiogram: Generalized cardiac dilatation, particularly left size was larger than right side. Mild depressed LV systolic function. Small amount of pericardial effusion. Most likely, the lesions are caused by tuberculous myopathy.

Cardiomegaly, miliary tuberculosis

Case report Diagnosis: HIV-infected child with miliary tuberculosis, and herpes simplex keratitis Treatment: 1. Miliary tuberculosis : INH (15 MKD), RF (15 MKD), PZA (25 MKD), S(25 MKD) Herpes simplex keratitis: Acyclovir ointment 5 times/day 3. Cardiac dysfunction: Douzabox (1 tb tid), Enalapril (0. 125 MKD), Digoxin (6. 25 microgram. KD) 4. Anemia: Ferrous Fumarate Co (1. 5 tb OD) 5.

Case report Course of illness: After she received the anti-tuberculous drugs and cefotaxime for 4 days, the fever subsided Her abdominal pain decreased. She gained appetite. Her eye pain and photophobia slowly recovered. Her cardiac condition gradually improved. The heart size was within normal limit. The previous mediastinal (hilar) lymphadenopathy partially subsided. Although each nodule of the "miliary" pattern was smaller in size, the pulmonary infiltration persisted.

Temperature and pulse chart

Post-treatment CXR

Thyroglossal cyst

CT- thyroglossal cyst

Midline neck lump

Case report A 58 -year-old man with a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia presents to the emergency department with a large, painless mass on the anterior aspect of the neck. He reports that the mass developed over the past 3 days, preceded by a sore throat and mild subjective fevers for several days

Case report He denies having any associated dysphagia, hoarseness, drooling, or stridor. He denies having a history of neck or oropharyngeal trauma, weight loss, night sweats, or cough. He has no history of tobacco use or alcohol abuse.

Case report On physical examination, the patient is a healthyappearing Asian man in no apparent distress. No hoarseness is noted. The oropharynx has no notable lesions or apparent mass effect. On the anterior aspect of the neck is a 2 X 3 -cm, smooth, soft, ovoid mass extending from the hyoid to the cricoid cartilage

Case report • The mass elevates when the patient swallows or protrudes his tongue. • On direct visualization with flexible laryngoscopy, the posterior part of the nasopharynx appears normal. The airway is clear and patent, without evidence of mass or external compression. The true vocal cords appear normal. • Laboratory results, are within normal limits. • A CT scan of the neck is ordered. • What is the diagnosis?

Thyroglossal cyst Location- between the thyroid isthmus-hyoid bone Close to the midline Spherical and smooth Hard consistence- high tension within the cyst Fixed to the hyoid bone Moves upwards when the tongue is protruded

Thyroglossal cyst Cysts of the thyroglossal duct result from hypertrophy of the remnants of the embryological thyroglossal duct tract Typically atrophies during the 10 th week of development

Pathogeny The stimulus for the sudden expansion of a chronically present tract is often an upper respiratory tract infection, which results in lymphoid tissue enlargement that occludes the tract and that results in cyst formation.

Thyroglossal cyst Patients with thyroglossal duct cysts usually present with an asymptomatic, cystic midline mass in the upper part of the neck, often after an upper respiratory tract infection. The cyst may be slightly tender and occasionally results in mild dysphagia. The cysts may occur anywhere along the tract of the thyroglossal duct from the foramen caecum of the tongue to the thyroid gland. The typical cyst moves up when the patient swallows or protrudes the tongue because of the anatomic attachment to the hyoid and larynx. Treatment is surgical excision of the thyroglossal duct cyst.

Branchial cyst Congenital lesion- arising from epithelial remnants of a branchial cleft ( pharyngeal groove) It may not distend and cause symptoms until adult life Painless swelling in the upper lateral part of the neck It lies behind the anterior edge of the upper third of SCM. muscle and bulges forwards Pain is caused by infection It may fluctuate but cannot be reduced or compressed

Branchial cyst

A cyst in the posterior triangle of the neck is extremely rare – case report A 23 year old female presented with a solitary swelling in the left side of the neck of 6 months duration. Initially the swelling was small, and gradually increased to attain the size of an apple. There was no pain in the swelling.

Physical examination On examination an 8 cm x 7 cm swelling was found in the left posterior triangle of the neck. It extended from the anterior border of the left sternomastoid to the anterior border of the left trapezius, anteroposteriorly and from the level of the thyroid prominence superiorly to about 3 cm medial to acromion process inferiorly. The smooth, well-defined swelling was fluctuant and transluminant

Case report On operation a well-circumscribed unilocular cyst was found without any connecting tract or cord to the skin or the pharynx. The cyst contained clear yellowish fluid. Microscopic examination of the cyst wall revealed a focally preserved flattened cuboidal epithelial lining.

Branchial cyst- anterior view

Branchial cyst- lateral view

Carotid body tumor Rare tumor, of the chemoreceptor tissue in the carotid body Location- upper part of the anterior triangle, level with the hyoid bone, beneath the ant. edge of SCM. Painless, slowing growing tumor The tumor pulsates Transient cerebral ischemia may be present

Carotid artery

Carotid bifurcation

Carotid body tumor

Examination of the thyroid gland First confirm that the swelling in the neck is in the throid gland- ask the pt. to swallow- the lump will move up Look at the whole pt. - calm or agitated, thin or fat, under-or over-clothed, moist or dry hands Palpate the pulse- tachy, bradicardic or irregular Look at the eyes: -lid retraction, exophtalmos, chemosis

Examination of the thyroid gland Palpate the neck from the front- nodule, trachea Palpate the neck from behind Look for laterocervical lymph nodes

Goitre Enlargement of the thyroid gland Diffuse or nodular Sollitary nodule or multiple nodules Site, shape, size, surface, tenderness, composition, relation

Nodular goitre

Nodular goitre

THYROTOXICOSIS Neck signs Eyes signs General signs

Exophtalmos

MIXEDEMA Neck Eyes General

Mixedema