7 - Neck Flashcards
Neck triangles?
Slide 4
Normal lymph node size in neck?
<1cm in length
> 1.5cm “enlarged”
Neck mass is usually? (Broken down by age)
> 40 = cancer
<30, >70 = lymphoma
Kids and young adults
- usually benign
Neck mass rule of 7’s?
7 days - inflammatory
7 weeks - 7 months - neoplastic
7 yrs - congenital
Neck abscesses?
Emergency
- can compromise airway
MC neck space infection
Ludwig’s angina
What is ludwig’s angina?
ENT emergency
- bilateral infectio of submandibular space
- tongue pushes up and blocks airway
Ludwig’s angina is often caused by?
Dental infection
MCC of deep neck abscess?
Odontogenic infections (dental)
Lemierre syndrome?
Rare cause of ludwig’s angina or deep neck abscess
- thrombophlebitis of internal jugular vein 2/2 orophangeal inflammation
Typical pt for lemierre syndrome?
ICU pts w prolonged internal jugular central venous catheter
S/s of lemierre syndrome?
Severe HA
Pulmonary infiltrates
Causes of ludwig’s angina and deep neck abscesses?
- Dental infection
- Lemierre syndrome
- Suppurative lymphadenitis
- Pharyngeal infection
- Penetrating trauma
- Pharyngoesophageal foreign bodies
- Cervical osteomyelitis
- Intravenous injection of internal jugular vein
Recurrent deep neck infection suggests?
Underlying congeintal lesion
- brachial cleft cyst
Suppurative lymphadenopaty in middle-aged pt with tobacco and ETOH hx is?
Metastatic SCC until proven otherwise
PE for deep neck abscess?
Edema
Erythemia
Pain in neck/chin/floor of mouth
Displaced tongue (2/2 cellulitis and pus)
MC cause of deep neck abscess?
Streptococci
Staphylococci
Bacteroides
Fusobacterum
Studies for deep neck abscess?
Contrast CT
CT/MIR can id lemierre syndrome
Tx for Ludwig’s angina?
PCN + metronidazole
Ampicillin-sulbactam
Clinamycin
Cephalosporins
Dental consult
I/D of external abscess
Deep neck abscess tx?
Secure airway
- intubate/tracheotomy
IV abx
I/D
Lemierre syndrome tx?
Antibiotics for fusobacterium necrophorum + airway pathogens
MCC of neck masses of all ages?
Reactive cervical lymphadenopathy (LAD)
What is reactive cervical lymphadenopathy?
Painful enlargement of normal lymph nodes in response to infection/inflammation
- infection of pharynx, salivary glands, scalp
Reactive cervical lymphadenopathy prognosis?
Self-limiting and resolves spontaneously over weeks
Tx for reactive cervical lymphadenoapathy
Abx FNA if - >1.5 cm - hx of tobacco/etoh/ca - persistent
Common causes of reactive cervical lymphadenopathy (LAD)
Tumor:
- scc
- lymphoma
- mets
Infection:
- virus
- mycobacteria
- cat scratch disease
Clinical presentation of reactive cervical lymphadenopathy (LAD)
Firm, mobile, tender
Rapid increase in size (rule 7’s)
- nodes can become necrotic and abscess
R/o cancer of >40
Ddx of infectious lymphadenopathy?
Typical mycobacterial infection
- single non-painful lesion
Atypical (non-tb) mycobacterial infection
- kids, no TB hx
- leads to chronic fistula
Cat scratch disease
- bartonella henselae
Toxoplasmosis
- single node in posterior triangle
Mono
- acute pharyngitis
Syphilis
- should always be in ddx
i say spirochete borrelia burgodorferi, you say?
Lyme disease from the ixodes tick
Lyme HEENT symptoms?
75% of pts have HEENT symptoms
- Facial paralysis
- Dysesthesias (distorted touch)
- Dysgeusia (distorted taste)
- Cranial neruopathies
- HA
- Neck pain
- Cervical LAD
OSA vs snoring?
Snoring = noise
OSA = disruption of sleep (clinical eval)
Prevalence of snoring/OSA?
OSA
Males - 20-30%
Females - 10-15%
Snoring/OSA are attributed to?
Narrowing of the upper aerodigestive tract during sleep due to changes in:
- position
- muscle tone
- soft tissue hypertrophy
- laxity
S/s of snoring/OSA?
Snoring
Daytime somnolence
HA
Wt gain
May or may not have demonstratable apnea or hypopnea on formal testing
PE for snoring OSA?
Excessive oropharyngeal tissue
Retrognathia
Large neck circumference
Obesity
Epworth sleepiness scale (ESS)
Diagnostics for OSA?
Polysmnography - an overnight test to eval sleep d/o
Snoring/OSA tx?
Wt loss
PT
Non-surg
- mandibular advancement appliances
- CPA
- BiPAP
Surgical
- stiffen palate
- UPPP
- craniofacial procedure
- hypoglossal nerve stimulation (implantable neurostimulator)
uvulopaletopharyngoplasty (UPPP)
Throat and uvula trimmed, folded and sutured
- pic on 34
Difference between crichothyrodotomy and tracheotomy?
You can smoke cigarettes through a tracheotomy
Seriously google it crazy…
Crichothyrotomy: acute emergency
- less risk (pneumothorax, hemorrhage)
Tracheotomy:
- air way obstruction
- respiratory failure w prolonged vent
Why would you transition from intubation to tracheotomy?
Prevention of:
- Subglotic stenosis
- Aspiration pneumonia
- sleep apnea
MC congenital mass of the lateral neck?
Branchial cleft cyst
What causes the branchial cleft cyst?
Remnants of the embryological development of the neck
Presentation of branchial cleft cyst?
Soft, slow growing painless lesion anywhere along the sternocleomastoid
Typically appear on face near auricle
H/o infection
2nd/3rd decade of life
Dx of branchial cleft cyst
CT: cystic mass medial to SCM
Tx for branchial cleft cyst?
Excise completely along fistulous tracts
- recurrent infection/carcinoma possible but rare
Send to path
MC congenital mass on central neck?
Thyroglossal duct cyst
Thyroglossal duct cyst developes from?
Remnant occurring along the embryologic descent of thyroid
Presentation of thyroglossal duct cyst?
< 20 yo
Thyroglossal duct cysts are midline
- often just below hyoid bone
- moves w swallowing and tongue protrusion
Diagnosis for thyroglossal duct cyst?
TSH - indicates amount of thyroid tissue in neck
CT
Tx for thyroglossal duct cyst?
Surgical removal
- preop US to confirm position of thyroid
Sistrunk procedure
- resection of the thyroglossal duct to the base of tongue w removal of the cyst and medial segment of they hyoid bone
Lipomas, hemangiomas and neurofibromas are all?
Benign
Slow growing
No invasion
Where in the neck does cancer like to mets to?
Lateral neck area
Almost 95% of head and neck cancer is?
SCC
Pt population who get SCC in the neck?
Middle-aged to elderly
- upper aerodigestive tract carcinogen exposure
- cigarette smoke
- ethanol
So basically bikers (sorry “motorcycle enthusiasts”)
Head and neck cancer gets a triple endoscopy. WTF is that?
Triple endoscopy
- direct laryngoscopy
- bronchoscopy
- esophagoscopy
Conducted under anesthesia
Why is SCC in the neck bad?
Its like a super highway mets to:
- lymph nodes of neck
- lung
- liver
- bone
- brain
What is the condition knowns as unknown primary?
When the primary tumor cannot be found
- about 10% of the time
What type of endoscope is used for biopsy?
ENT surgeons use rigid endoscops b/c they are better for biopsy
But you can use both
Adult pt with lump on neck and not good reason for it>?
Cancer until proven otherwise
Get complete HEENT exam
Get triple endoscopy
SCC lesions need? (Diagnostic)
FNA of lymph node
- then find the primary cancer
SCC presentation?
Sore throat Referred otalgia Hoarseness Airway obstruction Fixed reactive LAD Tender Constitutional symptoms
Thyroid Cancer type prevalence?
Papillary carcinoma - 80% - slow Follicular carcinoma - 10% - more aggressive Medullary carcinoma - 5% Anaplastic (undifferentiated) - <2% - most aggressive
Rule of 7’s
<7 weeks
Suspect infectious source
- abx
- f/u 2-4 wks
- CXR, PPD
Rule of 7’s
7 weeks - 7 months
Suspect neoplasm
- CT w contrast and FNA
- Endoscopy
- Management based on histology and stage
Rule of 7’s
> 7yrs
Suspect congenital anomaly
- CT
- excisional biopsy
Neck tattoos used to mean “watch out motherfucker”
Now they mean “i’d like to read you poems about my vegan bicycle”
