1. Neck Lumps Flashcards
Describe the boundaries of and structures found within Division III of the neck?
egion III: middle third jugular nodes extending from the carotid bifurcation superiorly to the cricothyroid notch (clinical landmark), or inferior edge of cricoid cartilage (radiological landmark), or omohyoid muscle (surgical landmark).
Describe the boundaries of and structures found within Division IV of the neck?
Region IV: lower jugular nodes extending from the omohyoid muscle superiorly to the clavicle inferiorly.
Describe the boundaries of and structures found within Division V of the neck?
posterior triangle group of lymph nodes located along the lower half of the spinal accessory nerve and the transverse cervical artery. The supraclavicular nodes are also included in this group. The posterior boundary is the anterior border of the trapezius muscle, the anterior boundary is the posterior border of the sternocleidomastoid muscle, and the inferior boundary is the clavicle.
Describe the boundaries of and structures found within Division VI of the neck?
Anterior compartment group comprises lymph nodes surrounding the midline visceral structures of the neck extending from the level of the hyoid bone superiorly to the suprasternal notch inferiorly. On each side, the lateral boundary is the medial border of the carotid sheath. Located within this compartment are the perithyroidal lymph nodes, paratracheal lymph nodes, lymph nodes along the recurrent laryngeal nerves, and precricoid lymph nodes.
Congenital multioculated, cyst-like cavities, classically found in the left posterior triangle of the neck and armpits?
Cystic Hygroma (AKA lymphatic malformation or cystic lymphangioma)
Can be found at birth or in infant after URTI.
Increasingly dx using U/S
Large fluid filled sac on palpation.
Often seen in Turners syndrome
Tx = Monitor for airway obstruction, surgery or sclerosing agent (e.g. Bleomycin).
Congenital palpable asymptomatic midline neck mass below the level of the hyoid bone. The mass on the neck moves on protrusion of the tongue because of its attachment to the tongue via the tract of thyroid descent. Some patients will have neck or throat pain, or dysphagia.
Thyroglossal cyst.
Fibrous cyst that forms from a persistent thyroglossal duct.The cyst will NOT rise on swallowing (thyroid mass will), but will when the tongue is stuck out (whereas a thyroid mass will not)
Complications = Thyroglossal Fistua, Infection.
Tx = Thyroid Scans and Thyroid Function Studies Then Sistrunk procedure: surgical resection of the duct to the base of the tongue and removal of the medial segment of the hyoid bone. Recurrence rare.
List the lymph node areas of the head and neck according to the Rouviere classification?
Occipital, mastoid, parotid, facial, submandibular, submental, sublingual, retropharyngeal, anterior cervical and lateral cervical
Lymph nodes…
What is considered an abnormal size for lymph nodes? Which are the exception?
Normal lymph nodes should not be greater than 1 cm in size (except for jugulodigastric : 1.5cms)
What is the most common cause of palpable cervical nodes in children?
Innocuous viral or bacterial disease
What, in the cervical region of children, warrants a work up?
Isolated cervical masses are frequently due to serious disease and require work-up
What are the 3 steps to be taken first, when a patient presents with a neck lump?
History
Examination
Decide on Appropriate Tests
Which investigation should be used conservatively, when it comes to neck lumps and why?
Open biopsy – as it can adversely affect the outcome
Outline the steps involved in the neck examination?
Inspection: patient sitting exposed to the clavicles
Use both hands and work systematically
Depth / skin : e.g sebaceous cyst with punctum
Size, shape, surface, texture, fixity.
?tender, hard or rubbery, mobile postion.
Examine mouth, tongue, oropharynx
Bimanual palpation, facial nerve with parotid lumps
What structures should be examined during a neck examination, what pathology might be associated with each?
LYMPH NODES
Papate (Supra-clavicular - left sided enlarged lymph node – Virchows node, Anterior cervical chain, Posterior cervical chain, Sub-mental, Sub-mandibular, Occipital, Pre-auricular, Post-auricular)
MID-LINE
(Lymph nodes - often multiple, may suggest infection or malignancy
Thyroid gland - located below thyroid cartilage
Thyroid nodule - can be single or multiple - adenomas / cysts / malignancy
Thyroglossal cysts - painless / smooth /cystic – rises on tongue protrusion)
ANTERIOR TRIANGLE (ANT TO SCM) Salivary gland swelling – doesn’t move on swallowing Branchial cyst - often located at anterior border of sternocleidomastoid – present since birth Carotid aneurysm -pulsatile mass – bruit present on auscultation Carotid body tumour - transmits pulsation – can be moved side to side but not up & down (due to carotid sheath) Laryngocele - reducible tense mass – mass returns on sneezing or nose blowing
POSTERIOR TRIANGLE (POST TO SCM)
Lymph nodes - often multiple – can be rubbery or hard depending on etiology
Subclavian artery aneurysm - pulsatile mass
Pharyngeal pouch - may present as a reducible mass
Cystic hygroma - most commonly on left side – fluctuant mass – transilluminates
Branchial cyst
What should you assess in a neck lump?
(Some Lady’s Seem Really Cautious For They Only Try Anything Prudent)
Size – width / height / depth
Location – can help narrow the differential - anterior / posterior triangle / mid-line
Shape – well defined?
Consistency – smooth / rubbery / hard / nodular / irregular
Fluctuance – if fluctuant, this suggests it is a fluid filled lesion – cyst
Trans-illumination – suggests mass is fluid filled - e.g. cystic hygroma
Pulsatility – suggests vascular origin – e.g. carotid body tumour / aneurysm
Temperature – increased warmth may suggest inflammatory / infective cause
Overlying skin changes – erythema / ulceration / punctum
Relation to underlying / overlying tissue – tethering / mobility (ask to turn head)
Auscultation – to assess for bruits – e.g. carotid aneurysm
What two symptoms might be useful to look for in the setting of thyroid lumps?
Cachexia - malignancy
Exopthalmos / Proptosis
- Graves disease
What is Dysphonia?
Hoarseness
What is Odynophagia?
Painful swallowing, in the mouth (oropharynx) or esophagus. It can occur with or without dysphagia.
What is Globus?
Feeling of a lump in the throat.
What is involved with panendoscopy?
Endoscopic examination of the esophagus, larynx and bronchial tree, as well as possibly other structures of the upper digestive tract. Can include biopsying of suspect lesions
Describe the 80/20 rule for isolated neck masses in children and adults.
80% of isolated neck masses in children are benign
In adults, 80% of neck lumps are malignant (20% benign)
Swelling of the salivary glands, sometimes painful, that fluctuates with meals? Dx? Tx?
Sialolithiasis.
Express, marsupialize or submandibular gland excision
(http://www.merriam-webster.com/audio.php?file=sialo09m&word=sialolithiases&text=%5C-%CB%8Cs%C4%93z%5C)
With what device might salivary gland disease be visualised and treated?
Sialendoscopes Outer diameter 1.1mm Diagnostic and therapeutic procedures Dormier baskets / laser under direct vision Completes diagnostic loop
Condition common in children, characterized by inflammation of one or more lymph nodes of the neck? Dx Tx?
Cervical Adenitis Due to staph aureus Haemolytic strep Viral origin (most common) Infectiouss mononucleosis
Infequent causes
• Cat scratch, TB, Toxoplasmosis, histiocytosis
Name the three types of Branchial Anomalies studied?
- Branchial Cysts (most common)
- Fistula
- Sinus
Arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft?
Branchial Cyst
Usually presents as a smooth, slowly enlarging lateral neck mass that may increase in size after an upper respiratory tract infection.
More common in Males (60%)
More common on the left (60%)
Common on the upper 1/3 of the SCM muscle.
What investigations are appropriate for a branchial cyst?
Ultrasound
CT
Fine Needle Aspirate Cytology
How would a Branchial Cyst be managed?
If infected = Aspirate + IV Antibiotics.
Surgical excision if persistent/cosmetic
Differential Diagnoses for midline neck lump?
Thyroglossal Mass
Thyroglossal Duct Cyst
Skin Lesions
Dermoid Cyst
What are the red flags in a neck lump?
Very Large (>3cm) Persistent (especially in the adult) Multiple (especially in adult) Hard Associated with Head and Neck Symptoms Hx of Smoking and Drinking
Ipsilateral Otalgia with normal otoscopy?
You must perform the following examinations
Tonsils, Tongue base, supraglottic larynx and pharynx
Unilateral serous otitis?
Examine the nasopharynx since carcinoma can be a cause.
When should a panendoscopy be performed?
FNABX positive
FNABx negative with high risk patient
What procedure should follow a panendoscopy?
Direct biopsy, suspicious areas, CT/MRI, high risk anatomical sites - nasopharynx, tongue base, hypopharynx.
What is the most common tumour of the parotid gland?
Benign Pleomorphic Adenoma
A benign cystic tumor almost exclusive to the parotid gland, tail of the parotid gland near the angle of the mandible.
Warthin’s Tumour
Abundant lymphocytes and germinal centers, low risk of malignancy.
What are the 4 main types of benign tumours affecting the salivary glands?
Benign Pleomorphic Adenoma
Warthin’s tumour
Heamangioma
Lymphangioma
(Big Whopping Hefty Lumps)
What are the 4 main types of malignant salivary tumours?
Squamous Adenoid cystic Lymphangiosarcoma Mucoepidermoid Adenocarcinoma Mets
(SAMLAM)
In the case of a thyroid lump what would multi-nodular mass imply?
Multinodular implies very low risk of malignancy…reassurance
How should a single thyroid nodule be assessed
Clinical assessment
Histological assessment (FNA)
Radiological assessment (ultrasound)
Rarely C.T. unless retrosternal
When would CT be used in a single thyroid nodule assessment?
If the nodule was retrosternal
What are the main types of thyroid cancer?
Papillary and Follicular (85%)
Anaplastic (5%) and medullary (10%)
What are considered poor clinical prognosticators for thyroid masses?
Growing Fast V.cord palsy Solid Family hx Hx radiation exposure > 4 cm Lymph nodes Stridor / dysphagia
With what condition is Medullary Thyroid Cancer associated?
MEN
Which part of the thyroid does follicular type affect?
Capsule and veins
Thyroid carcinoma that commonly metastasize to lung and bone via the bloodstream?
Follicular
Thyroid carcinoma that commonly metastasizes to cervical lymph nodes.
Papillary
Thyroid carcinoma that commonly presents with pressure symptoms and raised calcitonin levels?
Medullary
Thyroid carcinoma that commonly presents in young females and has an excellent prognosis?
Papillary
Ddx for thyroid nodule?
Benign nodular goiter. Measurement of thyroid stimulating hormone and anti-thyroid antibodies will help decide if there is a functional thyroid disease such as Hashimoto’s thyroiditis present, a known cause of a BNG.
What are the relative advantages and disadvantages of total thyroidectomy?
TOTAL THYROIDECTOMY Multicentricity Local recurrence less Decreases risk of distant recurrence Anaplastic transformation RAI diagnosis Thyroglobulin
PARTIAL THYROIDECTOMY
Complications less likely
Mortality no different
Describe the work-up to be performed prior to thyroidectomy?
CXR/ C.T. Vocal cord check ECG ? Frozen section Inform patient of hoarseness, aspiration, stridor, Calcium supplements and Thyroxine.
