Home


Head & Neck Board Review Cases

Case 1. Your patient has a large mass on the tip of his tongue. His history of using chewing tobacco leads you to suspect oral cancer. Which group of lymph nodes would the cancer spread to first? Would your answer be different if the mass was on the posterior 1/3 of the tongue? on the anterior 2/3 of the tongue in the midline? Which portions of the tongue have lymphatics that drain to the opposite side?


Case 2. A misguided hockey puck flies into the stands and hits a spectator on the lateral side of the head. The spectator loses consciousness for several minutes, then complains of a severe headache. A doctor in the stands examines the victim and finds swelling in the region of the pterion; she immediately calls 911. What is the pterion a landmark for? What does the doctor suspect has happened to the victim? Why is this type of hematoma a medical emergency? Explain the different sources of blood in epidural, subdural, and subarachnoid hematomas.


Case 3. Your patient has a swelling in the anterior part of his neck near the hyoid bone. You suspect that it might be a thyroglossal duct cyst. How does the thyroid gland develop? What are thyroglossal duct cysts, and where are they usually located?


Case 4. After examining your patient’s MRI, you discover that she has a small aneurysm in the wall of the internal carotid artery. She is also unable to abduct her left eye. Where is the aneurysm located? Why can’t the patient abduct her left eye? If the aneurysm burst, would the patient be able to see out of her left eye (i.e. would the left eye receive any blood)?


Case 5. A trauma patient with a large gash in her neck needs stitches. You decide to anesthetize the area with a cervical plexus block. What surface landmark would you use to guide your needle to the correct location? Where in relation to this landmark would you inject the anesthetic? What is the name for this location? Could the block affect other nerves in the posterior triangle? Which ones?


Case 6. Your patient complains of severe pain just anterior to her left ear, which is accentuated when she chews. She is also having problems with chewing – especially with food collecting in the space between her cheek and teeth, and food dribbling out of the corner of her mouth. Upon visual inspection, you notice that her left lower eyelid and corner of the mouth are drooping. An MRI reveals a parotid tumor. Explain how a parotid tumor could cause your patient’s symptoms.


Case 7. You are having a busy day during your ENT rotation – you have already seen one patient with a cleft lip, and another with a cleft palate. How do the lip and palate normally develop? What goes wrong in children with cleft lips or palates?


Case 8. You are performing surgery to remove a thyroid tumor that has invaded the root of the neck. After surgery, you notice that your patient has the following symptoms on the right side of her face: constricted pupil, ptosis, vasodilation and absence of sweating. What is your patient’s problem? How did it occur? Explain why your patient exhibits the above symptoms.


Case 9. Your patient was in a car accident and has fractured his mandible. Upon examination you notice that he has lost sensation on the left anterior 2/3 of his tongue, and his tongue deviates to the left when protruded. Which nerves were damaged in the accident? (specify right or left) Assuming that these were the only nerves damaged, would your patient have sensation in his left cheek? What about his left lower teeth?


Case 10. You discover a suspicious mole superficial to the right posterior triangle of your patient’s neck. You refer him to a surgeon to have it removed. Your patient returns because he is unable to effectively elevate his right shoulder (only very slight elevation is possible). He is also having a hard time abducting his right arm higher than 90º. Upon visual inspection, you notice that his right shoulder is drooping, i.e. lower than the left shoulder. Your patient’s ability to turn his head in both directions is normal. What is your diagnosis? Why wasn’t your patient’s ability to turn his head affected?

Answers to Head & Neck Board Review Cases


Case 1. Cancer on the tip of the tongue would spread to the submental lymph nodes. Tumors on both the posterior 1/3 of the tongue and the anterior 2/3 (midline) would spread to the deep cervical nodes. Lymph from the lateral parts of the anterior 2/3 drains to the submandibular nodes. Lymphatics from the midline of the tongue (all parts) drain bilaterally – i.e. there is crossing over to the opposite side. Lymphatics from the lateral parts of the tongue drain unilaterally.


Case 2. The anterior branch of the middle meningeal artery is found deep to the pterion on the interior aspect of the calvaria. Therefore, the doctor suspects that this artery has been torn by a skull fracture in that region, resulting in an epidural hematoma. This type of hematoma is a medical emergency because blood rapidly accumulates in the epidural (extradural) space and compresses the brain. Left untreated, a person can die in several hours. In contrast, subdural hematomas are venous in origin – usually a blow to the head causes a cerebral vein to be torn from its junction with the superior sagittal sinus. Subarachnoid hematomas usually result from a ruptured aneurysm of a cerebral vessel (e.g. internal carotid artery).


Case 3. The thyroid gland begins it development in the floor of the pharynx, at a site marked by the foramen cecum of the tongue. It subsequently descends into the neck passing anterior to the hyoid bone and thyroid cartilage. While it is descending, it remains attached to the tongue by the thyroglossal duct. Normally the duct disappears, however remnants may form thyroglossal duct cysts in the midline of the neck. 50% of these cysts are located near the hyoid bone. If a thyroglossal cyst ruptures, a thyroglossal fistula is produced (cyst connected to the outside). Accessory thyroid tissue can also be found along the migratory pathway.


Case 4. The aneurysm is located on the internal carotid artery within the cavernous sinus. It is compressing CN VI resulting in paralysis of the lateral rectus muscle. If the aneurysm burst, blood flow to the ophthalmic artery and the central retinal branch would be severely reduced (because it is leaking out of the internal carotid before the ophthalmic arises). If blood flow to the retina is deficient, blindness results (branches of the central retinal artery are end arteries).


Case 5. Since the cutaneous branches of the cervical plexus emerge along the posterior border of the SCM muscle, the SCM is the surface landmark you would use. You would inject the anesthetic along the posterior border of the SCM at the junction of its superior and middle thirds. This location is called the “nerve point of the neck”. The anesthesia could potentially affect the accessory nerve within the posterior triangle (with a deep injection), or the phrenic nerve due to its origin from C3 and 4.


Case 6. Your patient feels pain anterior to her ear because of referred pain sensations through the auriculotemporal nerve (supplies GSA to parotid gland). Pain is accentuated when she chews because the enlarged gland is being compressed against the mastoid process when the mouth opens (enlarged glands often extend past the posterior border of the mandible). Your patient’s other clinical problems are related to compression of the facial nerve by the parotid tumor. The problems with chewing are caused by paralysis of the buccinator; the lower eyelid is droopy because the inferior fibers of the orbicularis oculi are paralyzed; the corner of the mouth sags because the levator anguli oris is paralyzed. The specific branches of facial nerve that innervate the above muscles (in order) are buccal branch, zygomatic branch and mandibular branch.


Case 7. Normally the medial nasal, lateral nasal, and maxillary prominences come together to form the lip, palate and most of the nose. The medial nasal prominences contribute to the upper lip (philtrum), primary palate and the middle part of the nose. The lateral nasal prominences form the lateral parts of the nose (alae). The maxillary prominences form the cheeks, lateral parts of the upper lip, and the secondary palate (via the palatine shelves). If the prominences do not fuse properly, problems such as cleft lip and palate will result.


Case 8. While the surgeon was removing the thyroid tumor, he accidentally severed the sympathetic chain in the neck – the result is a condition called Horner syndrome. The patient’s symptoms can be explained by the fact that the head is not receiving any sympathetic fibers. Sympathetics normally dilate the pupil, elevate the upper lid (superior tarsal muscle), constrict blood vessels in the face and cause sweating. A lack of sympathetic fibers would produce the opposite effects: pupillary constriction, ptosis, vasodilation in the vessels of the face and absence of sweating.


Case 9. The left lingual nerve (sensation anterior 2/3) and left hypoglossal nerve (most tongue muscles including all protruders) were damaged. The tongue deviates to the left, because the tongue muscles on the right side are unopposed. Sensation of the left cheek and lower teeth would not be affected, because these are innervated by the buccal and inferior alveolar nerves, respectively.


Case 10. The accessory nerve has been severed in the posterior triangle. The accessory nerve provides innervation to trapezius (elevates, retracts and laterally rotates scapula) and sternocleidomastoid (laterally flexes neck and turns to one side). The affected shoulder droops and elevation is affected because the trapezius is the primary muscle that elevates and holds the scapula “up”. Levator scapula is a weak elevator. Retraction is not significantly affected because the rhomboids are strong retractors and can compensate. Lateral rotation of the scapula is necessary for full abduction of the humerus; therefore full abduction is weakened (serratus anterior can also rotate the scapula). The innervation to the SCM was not affected because it receives branches from the accessory nerve before the nerve enters the posterior triangle.

Additional cases without answers

1. While engaged in a snowball fight, a girl gets hit in the nose with a particularly hard snowball. Blood is spurting out her nose. Why does she bleed so profusely?

2. A teenager with severe acne develops a boil on the side of his nose. His physician cautions the youth that to pick or squeeze the boil could have life threatening consequences. Explain.

3. A child recovering from a sore throat and cold develops a middle ear infection. Why does it hurt and how did the infection reach the middle ear?

4. A man recovering from a viral inner ear infection loses control of the left side of his face overnight. His physician diagnoses Bell’s palsy. What nerve is affected? Besides facial paralysis, what other symptoms might the patient exhibit?

5. A patient diagnosed with tic douloureux is experiencing extreme pain on the cheek and side of his nose. What nerve is affected?

6. Your patient recovering from a severe cold complains of a frontal headache and a dull aching pain on the right side of her face. Explain the pain distribution.

7. Your patient has a cancerous thyroid gland surgically removed. A month after surgery her voice is still hoarse. What nerve has been damaged?

8. Your patient has parathyroid adenoma. During surgery you find the two superior parathryoid glands and a single inferior parathyroid gland, all of which appear normal. You can’t find a fourth gland related to the thyroid. Where might you look for the missing cancerous gland?

9. While eating dinner a man chokes on a fish bone. In the ED you examine his larynx with a laryngeal mirror. What normal structures would you visualize in the scope? What is the most likely site of the offending fish bone? What nerves might be injured if the bone pierced the mucosa?

10. While biopsing a suspicious deep cervical lymph node you cut ansa cervicalis. What muscles are paralyzed?

11. In another surgical case your resident cuts the external laryngeal nerve. What are the consequences?

Back to Board Review