Transcript ENT_examination

Examination of OtoRhino-Laryngology
Patient
. Dr. Mohammed Al-Tuwaijry
Senior Consultant and Head
Department of Otorhinolaryngology
Otorhinolaryngology / HNS –
 What is it?
 5- 6 years residency
 “Otto” – Ears
 “Rhiino” – Nose (+siinuses)
 “Laryngollogy” – Throatt (Aiirway)
 Head & Neck Surgery –Skullll base,,
Salliivary gllands,, Face,, Neck
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General scheme of patient
examination
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Personal history
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Beside the general information gained
from the personal history in general for
ear- nose and throat patient, special point
should be expressed:– At the beginning of the history –
Face –
 Pallor
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- Anemia
- Chronic toxemia
- Sever hemorrhage
 Movement
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- Paralysis
- Twitches
 Scars
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- Old trauma
- Surgery
Swellings
and orbital fissure
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Acute - abscess – trauma
Chronic – desmoids
lacrimal sac disease
Frontal sinus mucoceal
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Swellings
Orbital fissure
- Symmetrical or not
- Proptosis
1) Bilateral – thyroid, exophthalmus
2) Unilateral
- Orbital tumor
- Sinus diseases
- Unilateral pulsating prptosis with echymosis =
- epiphora
Bilateral – allergic or infective conjunctivitis.
unilateral – lacrimal drainage blockage
covernus sinus disease.
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Eyes in the central of face.
Look for deviations, swellings, or scars.
 Auricle left and right symmetrical normal in
shape and projection.
 Nose the upper lip and apex up between
the two eyes. Congenital deformity such as
cleft, dermoids, heamangioma, sinuses and
fistulas.
Talking to the patient
 Normal voice of the patient
 Hoarseness of voice – laryngeal disease
 Breathy voice – chest disease
 Nasal tone – nasal disease or naso pharyngeal
disease
 Aphonia – hysterical or after removal of larynx
 Articulation defect- pathology in lips, teeth, palate
or tongue
Hearing evaluation
Normal hearing patient hears the normal
conversation.
 Weak hearing:-patient hears loud
conversation.
 Sever hearing loss: - patient can't hear
very loud speech.
 In conductive hearing loss the patient
voice is low, but in sensory neural hearing
loss the patient voice is high.
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Memory and orientation:Normally the patient is oriented in time
and place and can tell his disease story
very clearly.
 Abnormal patient can't tell his disease
story and if you ask him about recent
events of his daily life he will not
remember.
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Occupation
 Working in dust:- expect allergy, chronic rhinosinusitis, chest
problems.
 Wood dust:- cancer maxilla.
 Fumes and chemicals:- allergy, asthma rhinosinusitis,
laryngitis.
 Teachers and singers:- chronic laryngitis with possible
nodules.
 Drivers: - baro truma (otitis media, sinusitis), vertigo, due to
rapture of round window membrane, perforation of tympanic
membrane.
 Mushroom pickers and birds farmers:- allergic rhinitis and
asthma due to fungus.
 Green houses and nursery: - allergy and asthma due to
chemicals and fertilizers.
Special habits
- Smoking: - chronic rhinosinusitis,
pharyngitis, laryngitis, bronchitis and
tumors.
 - Drinking alcohol:- chronic laryngitis,
hyperacidity and tumors.
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Complaint (C/O):-
Should
be written
down in patient
words.
Past history:
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Medical problems
- High blood pressure: - headache, bleeding, dizziness, tinnitus.
- Diabetes: - recurrent infections; necrotizing otitis externa, sensory
neural hearing loss, neuropathy, mucous membrane fungal infection
- Asthma: - with or without allergic rhinitis, chronic throat infections,
breathy voice.
- Renal disease: - sensory neural hearing loss.
- Rheumatic disease: - TMJ arthralgia, pain and headache.
- Hormonal imbalance: - thyroid exophthalmoses, hearing loss in
hypothyroidism.
- Liver failure: - bleeding from mouth and nose.
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Drug allergy or complications
- Aspirin allergy.
- Oto-toxic drugs & Vestibule-toxic drugs
- Nasal blockage with beta blockers.
- Nasal bleeding with anti- coagulants.
Surgical problems:- previous surgery of the diseased organ or
complications of surgery or anesthesia.in general
Trauma:- Noise – hearing loss.
- Chemical- chronic sinusitis, laryngitis, anosmia.
- Accidental – organ loss or deformity
Allergic syndrome:- allergy is a systemic disease, which may give
the following clinical diseases, rhinitis, conjunctivitis, asthma,
eczema, laryngitis.
History of psychic problems.
History of present illness
Onset – course of the disease – other
symptoms that may arise from the same
organ.
 - What increase or relieve the symptoms?
 - History of same disease before. And
what medications given and what was the
results of investigations?
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General examinations
Examine the pulse, temperature, blood
pressure (standing and laying down in
dizziness).
 Examine the cranial nerves and the
nervous system.
 Examine the lymph nodes, liver and
spleen when malignant tumor is
suspected.
 Examine the chest and heart.
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Local examination
Inspection.
 Palpation.
 Endoscopy.
 Microscopy.
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Nose examination
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Nose is a pyramidal structure projecting in
the midline of the face at the middle third,
with the base at the upper lip and the
apex between the orbits (root of the
nose).
– External nose examination – inspect the
skin for swellings, ulcers, deviations humb,
scars and abnormal colouration. Palpate for
tenderness on the bony nose floor of frontal
sinus and maxillary sinuses.
Internal nose
lateral wall
ostea
Medial wall
– Internal nose examination- rise the tip
with your finger and look inside the nose to
see the skin of vestibule and part of nasal
mucosa, then with nasal speculum examine
the left and right nasal cavities, look for:
Colour of mucous membrane
– Normal- smooth glistening reddish white.
– Acute rhinitis- congested red smooth.
– Chronic rhinitis- congested red non smooth.
– Allergic rhinitis – bluish white/
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Amount, color and consistency of secretions
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Normal- minimal amount of clear mucous.
Acute rhinitis – profuse amount.
Chronic rhinitis- mucoperulent discharge.
Allergic rhinitis- profuse clear mucous discharge with swelling.
Clear water discharge – CSF.
Bloody discharge tumor or grannuloma.
Fresh blood epistaxis.
Nasal septum deviation.
Inferior and Middle turbinate.
Floor of the nose.
Inferior and middle meatus.
Presence of abnormal growth
Clinical aspects of nasal
disease
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Nasal obstruction.
 Nasal discharge
 Fetor
 Epistaxis
 Smell disturbance
 Facial pain
 Facial deformity
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Specific diagnostic methods
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a) Nasal endoscopy
b) Biochemical and immunologic investigation of the
secretions
c) Cytology and bacteriology
d) Allergic investigation
e) Biopsy
To complete examination of the nose, the naso pharynx
should be examined with endoscopy through the nose or
with mirror through the mouth.
– X-Ray conventional for sinuses and nasal bones in case of
trauma, but C.T. is much more diagnostic.
Ear examination
– Inspect the auricles for shape,
– redness, swelling,
– ulceration, tumors,
– fistula, and
– retroauricular skin.
– Palpate the auricles for
– tenderness and pre or
– post auricular scar /swelling or
– tenderness.
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Inspect external canal Pull the
auricle upward backward in adult or
backward downward in infants and
young children to see the external
canal, which is S shaped, by this
movement you find out if there is
tenderness or not. Tenderness means
otitis extena .
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The length of external canal 25mm, the outer
third is cartilaginous lined with hairy skin and
cerumen glands, and the inner tow thirds is
bony. Normally the skin is smooth with some
soft cerumen, the bottom of the canal is closed
by the tympanic membrane, which is oval,
gryish white, glistening, mobile membrane. It is
oblique and concave. It shows the handle of
malleus hanging downwards backwards and
cone of light in the antro inferior sector.
Examination to be done at this stage with
otoscope or microscope.
TYMPAMIC MEMBRANE -NORMAL
CHRONIC PERFERATION
Chronic O.M.
Traumatic perferation
– . Tympanic membrane may be : Red congested…. Acute otitis media
 Atrophic retrscted with prominent handle of malleus
in long standing negative pressure- Secretory or
adhesive otitis media.
 Thick with calcification white in color ….
Tymanosclerosis.
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Perforated – central ….. marginal
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e) Ear discharge
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Brown mass – wax
Moist keratin debri – otitis externa
Moist dirty mass- fungus.
Mucoid or mucoperulent discharge- chronic or acute
otitis media.
Scanty offensive perulent discharges –
cholesteatoma/
Clear fluid – C.S.F.
Bleeding – trauma, tumor.
Serosangious discharge- polyp, viral otitis media, and
traumatic rapture of tympanic membrane.
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Special test
– Tuning fork test
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Weber's test – place the fork 512Hz in the midline on the for head
or upper central incisors. The patient may hear– Equal in both ears= normal.
– Better in the diseased ear- conductive hearing loss.
– Better in the normal ear- sensory neural hearing loss.
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Rinne's test – the fork is placed one inch opposite the external
canal, tell the patient stop hearing, then the fork is moved to the
mastoid bone behind the earR.N… positive- the air conduction is better than bone conduction=
normal hearing or sensory hearing loss.
R.N.. negative- the bone conduction is better than air conduction =
conductive hearing loss.
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Audiometry
Pure tone audiometry
Tympanometry
A.B.R. [ Auditory Brain Response ]
– X-ray
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Covential x-ray mastoids
C.T. brain and skull base with or without contrast
M.R.I.
Functional assessment of the Eustachian Tube.
- Valsalva's test
- Tympanometry – for both intact membrane or dry
perforation.
Examination of mouth and
pharynx
Oral cavity is bounded anteriorly by the lips,
and posteriorly by the anterior faucial archs,
inferiorly by the floor of the mouth, and
superiorly by the hard and soft palates. It is
divided into regions and areas for clinical
examination: Mouth vestibule – stars from lips deeply outside
the dental arches. The Stensen's duct of parotid
open opposite the second upper molar teeth.
 Dental arches with buccal gums and lingual
gums
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Mandible interfaces with skull base via the
TMJ and is held in position by the muscles
of mastication
 Divided into components with weakest
sites being the third molar area, socket of
the canine tooth, and the condyle.
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Fracture Frequency
Oral cavity proper –
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Tongue – the tip, the margins, the body, the base, the
dorsum, and the ventral surface. The upper surface is covered
by modified epithelium containing the filiform papillae and the
taste buds. The V shaped terminal sulcus separates the body
from the base of the tongue. The central point is the foramen
cecum, the remnant of the thyroglossal duct.
Floor of the mouth: - it is below the lower surface of
the tongue, the anterior part shows the openings of
Wharton's ducts of submandibular glands and
Bartholin's ducts of sublingual glands on both sides of
lingual frenulum. The epithelial lining of the oral cavity
consists of nonkeratinzed stratified squamous
epithelium with subepithelial collections of minor
salivary glands
Pharynx
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it is long muscular tube about 12cm in
length, extends from base of the skull
down to level of cervical spine No.6. it is
lined with mucosa and it is divided into
three parts:-
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Nasopharynx: - extends from the base of
skull down to the level of palate.
Anteriorly open in the nose, inferiorly
open in the oropharynx, laterally the
Eustachian tube open on ether side. The
epithelial lining is respiratory ciliated and
stratified squamous epithelium, with
transitional epithelium area.
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Oropharynx: - extends from the level of soft
palate down to the upper edge of the
epiglottis. It is continuous with the oral cavity
through the faucial isthmus. It has posterior
wall in front second and third cervical
vertebrae, the lateral wall containing the
palatine tonsil with anterior and posterior
faucial pillars. The epithelial lining consists of
nonkeratinizing stratified squamous epithelium.
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Hypopharynx:- extends from the upper
edge of the epiglottis superiorly to the
lower edge of cricoid cartilage it opens
anteriorly into the larynx and on each
side of the larynx lie the funnel-shaped
piriform sinuses inferiorly its continues
with esophagus the epithelial lining
consist of nonkeratinized stratified
squamusepithelium .
Clinical aspects of diseases of
the mouth and pharynx:
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Pain on eating, chewing or swallowing.
Dysphagia.
Pain the neck.
Globus symptoms.
Burning of the tongue.
Blood in the sputum.
Catarrh.
Oral fetor.
Disorder of salivary secretion.
Disorders of taste.
Respiratory obstruction.
Disorders of speech.
Swellings of the neck,floor of mouth and of the lymph nodes at
the angle of jaw and below the mandible.
Methods of investigation:
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Palpation: of lips, dental arches, floor of the
mouth for swellings ,submandibular area,
submental, TMJs
Inspection: by using tongue depressor, mirror,
flexible rigid endoscopy
Look for:
The color, symmetrical mobility of the lips, skin
of the lips, mucosa of lips and mouth vestibule.
The arrangement of the teeth, occlusion, dental
caries, temporomandibular joint mobility.
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The shape and mobility of the tongue, the upper surface
and inferior surface.
Mucosa of mouth, cheeks are examined for sensation,
ulceration, dryness, tumors.
The condition of hard and soft palate; smooth mucosa,
mobility of soft palate, swellings, ulcers.
Examine the parotid duct in the cheek opposite the
upper second molar tooth and the opening of
submandibular gland in the floor of the mouth on either
side of frinulum.
Examine the palatine tonsils:- size, crypts, cysts, ulcers
or tumor.
Radiography:
 Lateral view of the skull:- nasopharynx.
 Panorama of jaws:- dental cyst.
 Lateral view of the neck and upper thoracic region:- for
hypopharynx and cervical esophagus to show foreign
bodies.
 Contrast medium:- to show pharyngeal pouch, stenoses
and swallowing disorders.
 CT-SCAN for skull base larynx.
 Carotid angiography for the highly vascular tumors and
incases of bleeding for possible embolization of external
carotid branche,
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Microbiology:
 Culture for bacteriologic, Mycological and
virology examination.
 Biopsy:
 From any swelling which is not acutely
inflamed or suspected highly Vascular.
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LARYNX:
Embryology:
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The larynx develops from a two-part anlage: the
supraglottis develops from a buccopharyngeal bud, the
glottis and subglottis from a tracheobronchial bud. This
fact has clinical significance in the postnatal period.
 Anatomy:
 The laryngeal skeleton consists of the thyroid. Cricoid,
and arytenoids cartilages, ehich are hyaline cartilage, the
epiglottis, which is fibrous cartilage and the fibroelastic
accessory cartilages of Santorini and Wrisburg, which
have no function.
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The laryngeal cavity is divided
for clinical purposes into:
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Supraglottis.
Glottis.
Subglottis.
The vocal cords length is 0.7 cm. in the newborn, 1.6 to
2 cm. in women, 2 to 2.4 in men.
Functions of the laryngeal musculature:
Opening of the glottis, abduction of the vocal cordsPosterior cricoarytenoid muscle(posticus muscle)
Closure of the glottis adduction of V.C-Lateral
cricoarytenoid, transverse arytenoids, thyroarytenoid,
lateral part.
Tension of the vocal cords-Cricothyroid muscle,
thyroarytenoid muscle, medial part ( vocalis).
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The nerve supply:
1) Superior laryngeal nerve:
a) Sensory internal branch supplies sensation
down to the glottis.
b) External branch the motor supply to the
external cricothyroid muscle.
2) The recurrent laryngeal nerves left and right
gives motor supply to the internal laryngeal
muscles and sensation to the laryngeal mucosa
below the glottis.
Lymph drainage:
 No lymphatic capillaries in the vocal cord.
 Supraglottic drain in the superior cervical
lymph nodes.
 Subglottic dran in inferior cervical lymph
nodes, prelaryngeal, pretracheal nodes.
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Functions of the larynx:
Phonation.
 Respiration.
 Protection of the lower airway:
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Closure of the aditus.
Closure of the glottis.
Reflex respiratory arrest.
Cough reflex.
Fixation of the thorax aided by glottic closure.
Symptoms of laryngeal disease
– Hoarseness
– Stridor:- inspiratory type.
– Irritative cough
– Dysphagia
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Pain in the neck, which may radiate to the
ears
Examinations of the larynx
Inspection of the larynx
 Normally, the throid prominence can only be
seen in men. It moves upward on swallowing;
absence of this movement indicates fixation of
the larynx by infection or tumor.
 Indrawing of the suprasternal notch on
inspiration combined with inspiratory stridor points to laryngotracheal obstruction by foreign
body, tumor, odema, etc.
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Palpation
The laryngeal skeleton and neighboring structures are palpated
during respiration and swallowing, paying attention to the
following:-
The thyroid cartilage.
The cricothyroid membrane and the cricoid cartilage.
The carotid artery with the carotid bulb which must not be confused
with neighboring cervical lymph nods; the palpating picks up
pulsations.
The simultaneous movement of the larynx and thyroid gland on
swallowing.
Laryngeal click: - normally it is present and you feel click
sensation by moving the larynx side to side. But when lost it
means there is increase in the thickness of pre- vertebral soft
tissue. This is present in post cricoid carcinoma or odema.
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Laryngoscopy
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Indirect laryngoscopy: - inspection by means of mirror or
telescopic system 90 degree.
Direct laryngoscopy:- Rigid - Flexable
By all the above methods examine the following
areas:Base of the tongue, both valleculae, lingual surface of
the epiglottis, piriform sinus, glossoepiglottic and
aryepiglottic folds, epiglottis, vestibular folds, vocal
cords, anterior and posterior commissures. The normal
colour of vocal cords is whitish, service is smooth, and
closed in the mid line when patient say's
eeeeeeeeeeeee
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Radiography
Plain views in the sagittal or lateral plane
for foreign body. C.T. scan, then
laryngography, then stroboscopy, then
biopsy.
Neck
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The upper border of the neck runs along the inferior border of the
mandible through the apex of the mastoid process to the external
occipital protuberance. Inferiorly, the neck ends in a plane formed
by the suprasternal notch, the clavicles, and the spinous process of
the seventh cervical vertebra.
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To examine the neck the following should be remembered:
Topographic anatomy of neck triangles and their contents.
Deep neck spaces and compartements and fascial plains.
Lymph node groups and from which organs or regions their afferent
comes
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Triangles of neck
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Postesior triangle
Between posterior border of sternomstoid muscle and
anterior border of trapezius muscle, the apexis at
surperior nuchal ,line and base is formed by
intermediate third of clavicle .
Anterior triangle of neck
Anteriorly bounded by midline of neck posteriorly
bouded by anterior border of stesnomastoid,
Superiorly :-the lower borders of mandible.
Apex:-at the saprasternal notes it is subdivided to
more smaller
Triangles:-
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Submental triangle .
Bounded by anterior belly of diagastric
muscle on either side and base is thee
body of hyoid bone apex is the
mondiabular diagastric fossa
- Look for lymph nodes.
- Lipoma.
- Cystic swellings.
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Submandibular triangle .
Bounded by anterior belly of diagastric
muscle and posterior bellies and base is
thee body of hyoid boneq apex is the
mandiabular diagastric fossa
- Look for lymph nodes.
- Lipoma.
- Cystic swellings.
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Carotid triangleBorders
- Posterior:anterior border of sternomastoid
muscle
- Inferior:superior belly of omohyoid muscle
- Superiorly:posterior belly of diagastric muscle
Look for:
- Lymph nodes
- Chemodectomas
- Branchial cysts
- Parotid tail enlargment
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Muscular triangle Borders
- Superiorly:superior belly of omohyoid
- Posteriorly:anterior border of sternomastoid muscle
- Anteriorly:medline of neck
In this triangle, there are many important organs;
Lareynx:with the thyroid cartilage projecting as adam,s
apple in the midline
Thyroid gland, trachea
So on examing this triangle think about laryngeal,
thyroidal, tracheal diseases and then for lymph nodes,
carotid body tumors, cysts, thymus disease.
Fascia:
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The cervical muscles, viscera, and carotid
sheath are enclosed in fascia which is partly
tight, partly loose, and partly incomplete.
– The superficial cervical fascia lies under the platysma,
encloses the sternocleidomastoid and tapezius
muscles, insered onto the hyoid bone, and extends
superiorly to the lower border of the mandible and
inferiorly to the superior border of the sternum and
the clavicles.
– The medial cervical fascia is multilocular system
enclosing the entire cervical viscera, the thyroid
gland, the esophagus, the trachea, the pharynx, the
hyoid, the clavicle, the upper part of the sternum, and
the scapula.
Superfacial layer of
The middle
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The deep cervical fascia forms a tight tube around
the deep cervical muscles arising from the spinous
processes of the bodies of the cervical spine. The
prevertebral layer is part of the fascial system
running continuously from the base of the skull to
the inferior end of the spinal column.
The deep cervical fascia is divided into the alar
fascia and prevertebral part lying directly on
bone. The prevertebral fascial space is thus
divided into two to form the “danger space”
Infection can spread directly within it into the
posterior mediastinum.
The deep
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Note:
the space between the superficial and middle
cervical fascia is closed inferiorly as a sac
because of their common insertion to the
sternum and clavicle. This prevents inferior
extension of infection. In contrast, the space
between the middle and deep cervical fascia
communicates freely below with the
mediastinum. This allows abscesses to track
downward and allows infection due to
esophageal injuries or surgical emphysema to
spread to mediastinum.
Spaces:
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The visceral space of the neck allows gliding movements. It lies
anterior and lateral to the middle cervical fascia and posterior to the
pharynx but anterior to the deeper cervical fascia.
The parapharyngeal space contains the neurovascular bundle and
has areas of contact with the Eustachian tube and the tonsil.
The submandibular space with submandibular glan is in contact with
the dental alveoli.
The sublingual space encloses the sublingual gland and is the site of
abscesses of the floor of the mouth.
The submental space is important in Ludwig’s angina.
The parotid space-contain parotid glands, Veins, Facial nerve,
Terminal branches of external carotid artery.
Cervical Lymphatic System:
There are about 200 lymph nodes located in the human neck.
The cervical lymphatic system is a component of the reticuloendothellial system
Superficial lymph nodes.
Submental-submandibular.
Facial.
Parotid-auricular.
Mastoid.
Occipital.
Deep lymph nodes groups
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Along the internal jugular vein.
Along the accessory nerve.
Laryngotracheothyroid.
Bronchomediastinal.
Method of the investigation:
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Inspection is oriented on those structures of the neck that
contribute to the profile and seeks lesion of the
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overlying skin(vascular signs, venous congestion, radiodermatitis,
pigmented nevi, and melanoma),
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as well as fistulous openings in branchiogenic fistula, swelling
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or indurations ( lymphadenopathy, tumors, abscesses).
The position and mobility of the head are examined looking for
spasm of the neck muscles, e.g. in abscesses, thyroiditis, and
torticollis..
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Palpation:
Palpation is carried out either from in
front or behind, and both sides are palpated and
compared. The head should be tilted forward to
relax the soft tissues.
For every swelling – the following points should
be memorized (remembered):Neck SwellingSiteTopographic description
Form and SizeSize in centimeters.
MobilityVertically or horizontally mobile, fixed
or adherent to the overlying skin.
Consistency Soft, elastic, fluctuant, firm
or hard.
 Pulsation,
 skin temperature,
 color.Comparison to the surrounding
tissues
 .Tenderness
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Deep neck lymph nodes
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Level I: Lymph node groups – submental and submandibular
Level Ia*: Submental triangle
Boundaries – anterior bellies of the digastric muscle and the hyoid
bone
Level Ib*: Submandibular triangle
Boundaries – body of the mandible, anterior and
posterior belly of the digastric muscle
Note: includes the submandibular gland, pre- and postglandular
lymph nodes and pre- and postvascular (relative to
facial vein
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and artery) lymph nodes
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Note: does not include perifacial lymph nodes
Level II: Lymph node groups – upper jugular
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Boundaries – 1) anterior – lateral border of
the sternohyoid muscle
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2) posterior – posterior border
of the sternocleidomastoid muscle
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3) superior – skull base
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4) inferior – level of the hyoid bone
(clinical landmark) or carotid
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bifurcation (surgical landmark)
 Level IIa* and IIb* are arbitrarily designated
anatomically by splitting level II
with the spinal
accessory nerve.
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Level III: Lymph node groups – middle jugular
Boundaries – 1) anterior – lateral border
of the sternohyoid muscle
2) posterior – posterior border
of the sternocleidomastoid muscle
3) superior – hyoid bone
(clinical landmark) or carotid
bifurcation (surgical landmark)
4) inferior – cricothyroid notch
(clinical landmark) or omohyoid
muscle (surgical landmark)
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Level IV: Lymph node groups – lower jugular
Boundaries – 1) anterior – lateral border of the sternohyoid
muscle
2) posterior – posterior border of the
sternocleidomastoid muscle
3) superior – cricothyroid notch (clinical
landmark) or omohyoid
muscle (surgical landmark)
4) inferior – clavicle
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Level IVa* denotes the lymph nodes that lie along the internal
jugular vein but immediately deep to the sternal head of the SCM.
Level IVb* denotes the lymph nodes that lie deep to the clavicular
head of the SCM
Level V: Lymph node groups – posterior triangle
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Boundaries – 1) anterior – posterior border of the
sternocleidomastoid muscle
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2) posterior – anterior border of the
trapezius muscle
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3) inferior - clavicle
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Level Va* denotes those lymphatic structures in
the upper part of level V that follow the spinal accessory
nerve. Level Vb* refers to those nodes that lie along
the transverse cervical artery. Anatomically, the division
between these to subzones is the inferior belly of the
omohyoid muscle.
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Level VI: Lymph node groups – [prelaryngeal
(Delphian), pretracheal, paratracheal, and
precricoid (Delphian) lymph nodes] - also known
as the anterior compartment
Boundaries – 1) lateral – carotid sheath
2) superior – hyoid bone
3) inferior – suprasternal
notch
Level VII: Lymph node groups – Upper
mediastinal
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Boundaries – 1) lateral – carotid
arteries
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2) superior – suprasternal
notch
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3) inferior – aortic arch
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Supraclavicular zone or fossa:
relevant to nasopharyngeal carcinoma
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Boundaries – 1) superior margin
of the sternal end of the clavicle
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2) superior margin
of the lateral end of the clavicle
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3) the point where the
neck meets the shoulder
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