
Contents
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Common presentations Common presentations
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Common problems and their causes Common problems and their causes
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Cough (chronic/severe) Cough (chronic/severe)
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Difficulty breathing (stridor) Difficulty breathing (stridor)
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Difficulty swallowing (dysphagia) Difficulty swallowing (dysphagia)
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Foreign body ingestion and aspiration Foreign body ingestion and aspiration
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Haemoptysis (coughing up blood) Haemoptysis (coughing up blood)
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Hoarse voice/loss of voice Hoarse voice/loss of voice
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Injuries Injuries
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Lumps and swellings (lateral side of neck) Lumps and swellings (lateral side of neck)
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Lumps and swellings (midline of neck) Lumps and swellings (midline of neck)
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Pain on swallowing (odynophagia) Pain on swallowing (odynophagia)
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Useful questions and what to look for Useful questions and what to look for
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Cough (chronic/severe) Cough (chronic/severe)
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Difficulty breathing (stridor) Difficulty breathing (stridor)
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Difficulty swallowing (dysphagia) Difficulty swallowing (dysphagia)
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Foreign body ingestion and aspiration Foreign body ingestion and aspiration
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Haemoptysis (coughing up blood) Haemoptysis (coughing up blood)
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Hoarse voice/loss of voice Hoarse voice/loss of voice
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Injuries Injuries
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Lumps and swellings Lumps and swellings
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Pain on swallowing (odynophagia) Pain on swallowing (odynophagia)
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Examination of the front of the neck Examination of the front of the neck
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Look Look
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Feel Feel
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Assessing a lump Assessing a lump
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What are you feeling for? What are you feeling for?
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Useful investigations Useful investigations
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Laboratory tests Laboratory tests
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Plain films Plain films
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CT/MRI CT/MRI
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Angiography Angiography
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Direct visualization techniques Direct visualization techniques
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Ultrasound Ultrasound
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Fine-needle aspiration Fine-needle aspiration
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Miscellaneous investigations (in outpatients) Miscellaneous investigations (in outpatients)
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Injuries to the front of the neck
Injuries to the front of the neck
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Applied anatomy of the larynx Applied anatomy of the larynx
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Zones of the neck Zones of the neck
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Initial considerations Initial considerations
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Types of injury that may occur following blunt trauma Types of injury that may occur following blunt trauma
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Types of injury that may occur following penetrating trauma Types of injury that may occur following penetrating trauma
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Assessing injuries to the front of the neck Assessing injuries to the front of the neck
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Overview of symptoms Overview of symptoms
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Assessing direct injuries to the larynx Assessing direct injuries to the larynx
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Investigations Investigations
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Management principles Management principles
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Non-surgical management Non-surgical management
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Indications for surgical exploration include: Indications for surgical exploration include:
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Difficulty breathing, noisy breathing, and upper airway obstruction Difficulty breathing, noisy breathing, and upper airway obstruction
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Stridor
Stridor
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Stertor
Stertor
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Assessment of stridor Assessment of stridor
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Upper airway obstruction
Upper airway obstruction
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Croup (laryngotracheobronchitis)
Croup (laryngotracheobronchitis)
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Epiglottitis (supraglottitis)
Epiglottitis (supraglottitis)
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Initial management of stridor Initial management of stridor
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Subglottic stenosis
Subglottic stenosis
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Congenital Congenital
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Acquired Acquired
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Management Management
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The acutely swollen neck
The acutely swollen neck
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Ludwig’s angina Ludwig’s angina
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Clinical features Clinical features
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Management Management
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Infections deep in the neck
Infections deep in the neck
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Applied anatomy Applied anatomy
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Superficial cervical fascia Superficial cervical fascia
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Deep cervical fascia Deep cervical fascia
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Commonly infected fascial tissue spaces in the neck Commonly infected fascial tissue spaces in the neck
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Submandibular space Submandibular space
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Submental space Submental space
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Signs and symptoms in deep neck infections Signs and symptoms in deep neck infections
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Management Management
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Choice of antibiotics Choice of antibiotics
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Some specific types of neck infection Some specific types of neck infection
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Necrotizing fasciitis
Necrotizing fasciitis
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Acute bacterial submandibular sialadenitis
Acute bacterial submandibular sialadenitis
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Chronic submandibular sialadenitis (Kuttner’s tumour)
Chronic submandibular sialadenitis (Kuttner’s tumour)
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Lump(s) in the neck
Lump(s) in the neck
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An important consideration An important consideration
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Applied anatomy Applied anatomy
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Triangles of the neck Triangles of the neck
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Overview of the anterior triangle Overview of the anterior triangle
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Contents of importance Contents of importance
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Overview of the posterior triangle Overview of the posterior triangle
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Contents of importance Contents of importance
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Miscellaneous anatomical structures and an overview of causes of lumps Miscellaneous anatomical structures and an overview of causes of lumps
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Sternomastoid muscle Sternomastoid muscle
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Omohyoid Omohyoid
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Platysma Platysma
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Causes of lumps in the neck Causes of lumps in the neck
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Assessing a neck lump Assessing a neck lump
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History History
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Useful information when diagnosing neck lumps Useful information when diagnosing neck lumps
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Age Age
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How long has the lump been present? How long has the lump been present?
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Is it painful? Is it painful?
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Does it vary in size? Does it vary in size?
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Does the patient have foul breath (halitosis) or a foul taste in their mouth? Does the patient have foul breath (halitosis) or a foul taste in their mouth?
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Ask about sore throat, unilateral hearing loss, earache, and hoarseness Ask about sore throat, unilateral hearing loss, earache, and hoarseness
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Other symptoms of systemic upset Other symptoms of systemic upset
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Has the patient travelled overseas recently? Has the patient travelled overseas recently?
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Are there other features of malignant disease? Are there other features of malignant disease?
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Are there features of thyroid disease? Are there features of thyroid disease?
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Examination Examination
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Neck node levels Neck node levels
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Investigations Investigations
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Plain films Plain films
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CT scanning CT scanning
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MRI MRI
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Fine-needle aspiration Fine-needle aspiration
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Ultrasound Ultrasound
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Sialography Sialography
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Examination under anaesthesia Examination under anaesthesia
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Lymphadenopathy
Lymphadenopathy
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Causes of enlarged lymph nodes Causes of enlarged lymph nodes
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Local causes Local causes
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Generalized causes Generalized causes
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Infections causing lymphadenopathy
Infections causing lymphadenopathy
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Bacterial cervical adenitis Bacterial cervical adenitis
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Atypical mycobacteria Atypical mycobacteria
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Non-specific lymphadenitis Non-specific lymphadenitis
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Cervical adenopathy in the patient with HIV Cervical adenopathy in the patient with HIV
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Persistent generalized lymphadenopathy (PGL) Persistent generalized lymphadenopathy (PGL)
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Cat-scratch disease Cat-scratch disease
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Tumours causing lymphadenopathy
Tumours causing lymphadenopathy
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Primary: Hodgkin’s disease and non-Hodgkin’s lymphomas Primary: Hodgkin’s disease and non-Hodgkin’s lymphomas
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Secondary: metastatic disease Secondary: metastatic disease
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Thyroid/thyroglossal cyst/thymus
Thyroid/thyroglossal cyst/thymus
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The enlarged thyroid gland The enlarged thyroid gland
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Goitres
Goitres
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Different types of goitres Different types of goitres
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Key questions Key questions
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Investigations Investigations
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Indications for thyroidectomy Indications for thyroidectomy
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The solitary thyroid lump (nodule)
The solitary thyroid lump (nodule)
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Different types of thyroid cancers Different types of thyroid cancers
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Risks factors for thyroid cancer Risks factors for thyroid cancer
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Thyroglossal duct cyst
Thyroglossal duct cyst
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Thymic cysts
Thymic cysts
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Carotid body tumour
Carotid body tumour
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Clinical features Clinical features
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Management Management
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Branchial cysts/sinuses/fistulae
Branchial cysts/sinuses/fistulae
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Branchial cyst
Branchial cyst
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Clinical features Clinical features
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Investigations Investigations
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Management Management
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Branchial sinus/branchial fistula
Branchial sinus/branchial fistula
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Summary of branchial cleft anomalies Summary of branchial cleft anomalies
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Plunging ranula
Plunging ranula
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Investigations Investigations
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Treatment Treatment
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Dermoid cysts and teratomas
Dermoid cysts and teratomas
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Dermoid cysts Dermoid cysts
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Management Management
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Cervical teratomas
Cervical teratomas
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Management Management
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The salivary glands The salivary glands
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Obstruction
Obstruction
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Infections
Infections
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Mumps Mumps
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Suppurative parotitis Suppurative parotitis
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Chronic sialadenitis Chronic sialadenitis
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Tumours
Tumours
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Salivary gland dysfunction
Salivary gland dysfunction
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Xerostomia (dry mouth) Xerostomia (dry mouth)
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Ptyalism (drooling) Ptyalism (drooling)
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Some useful facts Some useful facts
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Hoarse voice (dysphonia)/loss of voice
Hoarse voice (dysphonia)/loss of voice
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Components of speech Components of speech
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Assessment of a patient with dysphonia (usually as an outpatient) Assessment of a patient with dysphonia (usually as an outpatient)
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Character of dysphonia Character of dysphonia
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Contributing factors Contributing factors
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Associated symptoms Associated symptoms
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Assess perceptual quality of voice Assess perceptual quality of voice
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Examination Examination
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Videostroboscopy Videostroboscopy
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Aerodynamic studies and laryngeal EMG Aerodynamic studies and laryngeal EMG
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Vocal cord palsy and other conditions
Vocal cord palsy and other conditions
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Investigations Investigations
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Management Management
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Reinke’s oedema
Reinke’s oedema
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Management Management
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Vocal fold granulomas
Vocal fold granulomas
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Presentation Presentation
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Management Management
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Muscle-tension disorders/functional voice disorders
Muscle-tension disorders/functional voice disorders
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Conversion dysphonia
Conversion dysphonia
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Carotid artery disease
Carotid artery disease
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Carotid stenosis
Carotid stenosis
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Clinical features Clinical features
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Management Management
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Carotid artery dissection
Carotid artery dissection
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Management Management
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Coughing up blood (haemoptysis)
Coughing up blood (haemoptysis)
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Foreign body ingestion
Foreign body ingestion
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Foreign body in the oesophagus
Foreign body in the oesophagus
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Investigations Investigations
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Management Management
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Caustic ingestion
Caustic ingestion
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Investigations Investigations
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Management Management
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Miscellaneous conditions Miscellaneous conditions
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Eagle syndrome (styloid–carotid artery syndrome)
Eagle syndrome (styloid–carotid artery syndrome)
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Tracheostomy Tracheostomy
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Tracheostomy indications Tracheostomy indications
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Tracheotomy care Tracheotomy care
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Decannulation Decannulation
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Tracheotomy complications Tracheotomy complications
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Surgical (subcutaneous) emphysema
Surgical (subcutaneous) emphysema
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Aetiology Aetiology
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Management Management
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Mediastinal masses
Mediastinal masses
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Investigations Investigations
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Management Management
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Globus
Globus
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Cite
Abstract
This chapter looks at diseases and conditions of the front of the neck that may present acutely to an emergency department, general practice, or ward. It aims to equip the reader with the necessary knowledge to enable them to quickly and accurately triage and diagnose common clinical problems. Referral pathways and management are also discussed. Generally speaking, patients do not present with a ready-made diagnosis, but rather with either a symptom located to an anatomical region (e.g. toothache, lump, or headache), or an obvious problem (e.g. nose bleed or injury). This is the starting point (‘Common presentations’ and ‘Common problems and their causes’). The next section (‘Useful questions and what to look for’) lists key diagnostic elements in relation to each symptom. The remainder of each chapter details how to examine each site, useful investigations (emergency department and outpatients), and some notes on the conditions themselves. This is a useful aid for the non-specialist and those preparing for clinical examinations.
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