Cervical Lymph Nodes + Other Neck Lumps Flashcards
Role of the lymphatic system
- remove excess fluid from interstitial space
- restores small proteins + fluid that leaked from capillaries to veins
- immune defence + surveillance
What are clinical manifestations of diseases involving the lymphatic system?
Lymphadenopathy
Lymphoedema
What is lymphadenopathy?
Enlarged lymph nodes due to infection/inflammation or malignancy
Where can you palpate enlarged lymph nodes?
Cervical (Neck)
Axilla
Inguinal (Groin)
What is Waldeyer’s ring?
Annular collection of lymphoid tissue surrounding upper aero digestive tract (tonsils)
What lymph nodes can be palpable in well children?
Cervical lymph nodes
What are the different tonsils?
Pharyngeal tonsil/adenoids
Tubal tonsils
Palatine tonsils
Lingual tonsil
Location of pharyngeal tonsil + tubal tonsils
In nasal pharynx
Location of palatine tonsils
At back of throat
Location on lingual tonsil
Posterior surface of the tongue
What can enlargement of pharyngeal tonsil lead to?
- Obstruction of nasal breathing: mouth breathing, snoring
- Blockage of eustachian tube > middle ear problems
What is tonsillitis?
Enlargement of palatine tonsils
Is tonsillitis most commonly caused by viruses or bacteria?
Viral
What bacteria most commonly causes tonsillitis?
Strep pyrogenes
What two tools can be used to estimate the probability that tonsillitis is due to bacterial infection?
Centor criteria
FeverPAIN score
Outline the Centor criteria
What is it used for?
- Used to estimate the probability that tonsillitis is due to bacteria
- score >3 = 40-60% chance > offer antibiotics
. - fever >38C
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
Outline the FeverPAIN score
What is it used for?
- Used to estimate the probability that tonsillitis is due to bacteria
- score 2-3 = 34-40% chance
- score 4-5 = 62-65% chance
. - fever
- Pus on tonsils
- Attended within 3 days of onset of symptoms
- Inflamed tonsils
- No cough
Treatment of bacterial tonsillitis
phenoxymethylpenicillin for 10 days
clarithromycin is penicillin allergy
Complications of tonsillitis
- peritonsillar abscess
- otitis media
- scarlet fever
- rheumatic fever
- post-streptococcal glomerulonephritis
- post-streptococcal reactive arthritis
Outline superficial/regional cervical lymph nodes
- In superficial cervical fascia, just beneath skin
- Drains regions of face, scalp + tongue into deeper lymph nodes
- Form a ring from chin to occiput
Outline deep/terminal cervical lymph nodes
- Most associated with IJV within carotid sheath
- Drain lymph from superficial lymph nodes + directly from deeper tissues e.g. thyroid gland
What is the bony prominence of chin?
Mental protuberance
What is the bony protuberance of the occipital bone?
Occiput
What are the superficial cervical lymph nodes draining the face + scalp?
- submental
- submandibular
- pre-auricular + parotid
- post-auricular
- occipital
- superior cervical
- posterior cervical
- anterior cervical
What do the occipital lymph nodes drain?
Posterior scalp
What do the post-auricular lymph nodes drain?
Posterolateral half of scalp
What do the pre-auricular (+parotid) lymph nodes drain?
Anterolateral scalp
Upper half face including eye lids (conjunctiva)
Cheek
What do the submental lymph nodes drain?
Inferior + posterior chin
Floor of mouth
Tip of tongue
Lower incisor teeth + gums
What do the submandibular lymph nodes drain?
Centre of face + cheek
Teeth + gums
Anterolateral tongue
What are the deep cervical lymph nodes?
- jugulo-digastric
- jugulo-omohyoid
- supraclavicular
What do jugulo-omohyoid lymph nodes drain?
Part of tongue
Oral cavity
Trachea
Oesophagus
Thyroid gland
3Ts 2Os
What deep cervical lymph nodes are found in the posterior triangle?
Supraclavicular lymph nodes
Why is there reason to worry in the case of supraclavicular lymphadenopathy?
Strong suspicion of malignancy
What is an enlarged left supraclavicular lymph node suggestive of?
Gastric cancer
How do reactive lymph nodes feel (non cancerous)?
Tender
Mobile - doesn’t feel stuck to surrounding tissues
What features of enlarged lymph nodes suggests metastases?
Hard
Tethered to surrounding tissues
Painless to palpation
What features of enlarged lymph nodes suggests lymphoma?
malignant
Rubbery
Painless to palpation
Fast growing
What are red flags for lymphadenopathy?
- on palpation: fixed, hard, irregular
- rapidly grows in size
- associated with generalised lymphadenopathy
- systemic signs: weight loss, night sweats
- associated with persistent unexplained changes in voice, difficultly swallowing
History for neck lumps
Age
Duration
Progression
Associated symptoms
Potential risk factors
Examination of neck lumps
- Location: midline, anterior or posterior triangle
- Movement with swallowing
- Movement with sticking out tongue
Palpation feature of neck lump
- superficial or deep
- mobile or fixed
- hard, soft, rubbery, irregular
- does it feel fluctuant? Filled with fluid
- tender?
- overlying skin changes
Possible causes of neck lumps
- cervical lymphadenopathy
- benign lesions of skin or subcutaneous tissue
- congenital lesions
- thyroid gland pathology
- salivary gland pathology
- vascular
- dermoid cyst
- branchial cyst
What do the jugulo-digastric lymph nodes drain?
- tonsils
- pharynx
- part of tongue
What should you do if the submental or submandibular lymph nodes are enlarged?
Check mouth
- teeth
- gum
- tongue: tip, top, bottom
What could a midline neck lump be?
Dermoid cyst
Thyroglossal duct cyst
Pathology of the thyroid gland
Outline a dermoid cyst
- Congenital cystic teratoma
- Sits high on midline of neck
- teratoma > can contain hair, teeth or skin glands
Outline a thyroglossal duct cyst?
- congenital filled sac in the midline of the neck
- moves superiorly with protrusion of the tongue
- surgical removal (includes removal of hyoid bone)
What could a lateral lump in the neck be?
- pathology of salivary glands
- carotid body tumour
- branchial cysts
- cystic hygroma
What is a cystic hygroma?
- collection of fluid filled sacs
- in posterior triangle
- compressible + transilluminable
- often in young children
Management of cystic hygroma
Surgical excision
Drainage
Who do cystic hygromas occur in?
Infants + young children
Outline a branchial cyst
- congenital cyst on anterior superior SCM
- originates from incomplete obliteration of branchial arches
Investigations of neck lumps
- Ultrasound first line
- Fine needle aspiration if suspicious
- CR or MRI scans if needed further
What is the best imaging for neck lumps?
Ultrasound
What is a neck lump moves on sticking out the tongue indicative of?
Thyroglossal duct cyst
A patient, presenting with a neck lump, complains of pain after eating. What is the likely diagnosis?
Salivary gland pathology
A patient has a neck lump that moves on swallowing, what is the likely diagnosis?
Goitre
(thyroid gland swelling)
