Adult Neck Masses

Question 1

an abnormal lesion, congenital or acquired that is visible, palpable, or seen on an imaging study below the mandible, above the clavicle and deep to the skin

Answer 1

neck mass

Question 2

fluctuating in size = ___

persistently enlarging = ___

Answer 2

fluctuating = inflammatory or congenital

persistently enlarging = malignancy

Question 3

age difference in ddxs

Answer 3

pedia: inflammatory, congenital > neoplasm
adult: neoplasm > inflammatory, congenital

Question 4

t/f adult neck mass should be considered malignant unless proven otherwise

Answer 4

true

Question 5

detailed examination of the mass

Answer 5

appearance
borders
consistency and color
dimensions
extent
fixation

Question 6

borders of anterior triangle

Answer 6

S inferior border of mandible
L anterior border of the scm
M sagittal line down the midline of the neck
R investing fascia
F visceral fascia

Question 7

borders of carotid angle

Answer 7

S posterior belly of digastric muscle
L medial border of scm
I superior belly of omohyoid muscle

Question 8

contents of carotid triangle

Answer 8

common carotid artery
internal jugular vein
hypoglossal nerve
vagus nerve

Question 9

borders of submental triangle

Answer 9

I hyoid bone
M midline of neck
L anterior belly of digastric muscle
F mylohyoid muscle

Question 10

contents of submental triangle

Answer 10

submental lymph nodes (filters lymph from floor of mouth and tongue)

Question 11

borders of submandibular triangle

Answer 11

S body of mandible
A ant belly of digastric
P posterior belly of digastric

Question 12

contents of submandibular triangle

Answer 12

submandibular gland and lymph nodes

facial artery and veins

Question 13

borders of muscular triangle

Answer 13

S hyoid
M imaginary midline of neck
SL superior belly of omohyoid muscle
IL inferior portion of scm

Question 14

contents of muscular triangle

Answer 14

infrahyoid muscle
pharynx
thyroid gland
parathyroid gland

Question 15

most vital structures in ant triangle

Answer 15

thyroid gland
carotid and jugular
submandibular
lymphatics

Question 16

borders of posterior triangle

Answer 16

A posterior border of scm
I middle 1/3 of clavicle
P ant border of trapezius

Question 17

muscle that splits post triangle into 2 triangles

Answer 17

omohyoid muscle -> occupital triangle and subclavian triangle

Question 18

level 1 of lymph

submental and submandibular

Answer 18

lip, oral cavity, skin of lower face

Question 19

level 2 of lymph

upper jugular

Answer 19

oropharynx (tonsil and tongue)

parotid gland

Question 20

level 3 of lymph

mid jugular

Answer 20

hypopharynx and thyroid gland

Question 21

level 4 of lymph

supraclavicular

Answer 21

larynx, hypopharynx, thyroid, non-head or neck sits (lung, breast, gi, gu)

Question 22

enlarged __ indicated abdominal malignancy

Answer 22

virchow’s node

Question 23

level 5 of lymph

post triangle

Answer 23

scalp, lymphoma, nasopharynx

Question 24

level 6 of lymph

paratracheal

Answer 24

thyroid and larynx

Question 25

nasopharynx pe

Answer 25

e tube orifices, superior and posterior walls through nasal endoscopy

Question 26

hypopharynx pe

Answer 26

pyriform sinuses and post pharyngeal wall

Question 27

most frequently used modality for adults

Answer 27

ct scan (adults > pedia)

Question 28

uts is more used in ___

Answer 28

pedia and thyroid nodules

can distinguish between solid and fluid filled masses

Question 29

when to use mri

Answer 29

• most detailed anatomic soft tissue info

- best for salivary gland masses and determination of perineural extension

Question 30

when to use mra/cta

Answer 30

vascular structures (vascular tumors)

Question 31

what does pet scan do

Answer 31

• functional imaging
• bright spots = cells with higher metabolic rate
• detection and surveillance of h&n cancer

Question 32

indications for pet scan

Answer 32

• detection of unknown primary tumor site
• tumor staging
• radiotherapy planning
• treatment response assessment
• detection of recurrent disease

Question 33

initial method for obtaining pathologic tissue sample of neck mass

Answer 33

fna biopsy

Question 34

t/f there is no need to prepare a cell block

Answer 34

false, lymphoma is always a concern so always prepare cell block

Question 35

indications for fna

Answer 35

• single asymmetric node >1.5 cm
• persistent enlarged node without prior signs of active infection
• persistence after trial of antibiotics and observation >2-4 wks
• increasing size of mass

Question 36

local s/sx for infection

Answer 36

• warmth
• erythema of overlying skin
• localized swelling
• tenderness to palpation

Question 37

if (+) for infection ___

Answer 37

empiric broad spectrum antibiotic therapy (2 wks)

Question 38

if (-) for infection ___

Answer 38

determine signs of increased risk for malignancy, don’t give antibiotics

Question 39

increased risk for malignancy

Answer 39

• lack of hx of infectious etiology
• present >2 wks without significant fluctuation
• uncertain duration
• > 1 of ff:
  fixation to adjacent tissues, firm consistency, size >1.5 cm, ulceration of overlying skin

Question 40

other suspicious findings on hx and pe

Answer 40

read

Question 41

when to refer

Answer 41

• mass does not resolve within 2-4 wks following antibiotics
• sus malignant
• mass with rapid enlargement w/ or w/o inflammation
• thyroid/ salivary mass
• fixed mass

Question 42

indications for open biopsy

Answer 42

• > 2 cm and growing
• low cd4
• asymmetric, unilateral, or localized lymphadenopathy
• constitutional symptoms of unknown origin
• mediastinal adenopathy
• hepatosplenomegaly

Question 43

t/f incision biopsy should be avoided for metastatic sq cell carcinoma

Answer 43

true, look for the primary tumor, refer to specialist

Question 44

management

Answer 44

• surgical
• chemo for lymphoma
• tb meds for tb adenitis
• antibiotics for bacterial lymphadenitis