ENT: Neck Problems Flashcards
We can describe the location based on neck lump using following terms: anterior triangle, posterior triangle and midline. Remind yourself of borders of anterior triangle
- Superior border: inferior border of mandible
- Medial border: midline of neck/sagittal line down midline of neck
- Lateral border: anterior border of SCM
We can describe the location based on neck lump using following terms: anterior triangle, posterior triangle and midline. Remind yourself of borders of the posterior triangle
- Inferior border: middle ⅓ clavicle
- Posterior border: anterior border of trapezius
- Anterior: posterior border of SCM
State some potential causes of neck lumps in adults
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g., squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
State some potential causes of neck lumps in children
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
(obviously can have some of those seen in adults too- these ones are just more likely in children)
State some potential causes of lymphadenopathy
Causes can be grouped into:
- Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
- Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis)
- Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
- Malignancy (e.g., lymphoma, leukaemia or metastasis)
For carotid body tumours, discuss:
- What they are
- Presentation
- Treatment
- Excessive growth of glomus cells in carotid body- usually benign (glomus cells are the chemoreceptors, carotid body located just above carotid bifurcation. Also called paragangliomas as groups of glomus cells called paraganglia)
- Presentation:
- Slow growing lump in upper anterior triangle
- Painless
- Pulsatile
- Bruit on auscultation
- Mobile side-to-side but not up & down
- Can compress surrounding structures (CNIX, CNX, CNXI or CNXII. Pressure on vagus nerve may cause Horner’s)
- Most treated with surgical removal
For lipomas, discuss:
- What they are
- Presentation
- Management
- Benign tumours of adipose tissue
- Presentation of lump:
- Soft
- Painless
- Mobile
- No skin changes
- Management:
- Reassure & leave
- Or surgically remove
For thyroglossal duct cysts, discuss:
- What they are/how they are formed
- Presentation
- Key differential to consider
- Management
- In fetal development, thyroid gland starts at base of tongue and gradually migrates down the neck to final position in front of trachea beneath larynx; leaves a track behind called ‘thyroglossal duct’. Thyroglossal duct usually disappears but if it persists a fluid-filled cyst can form
- Presentation:
- Midline lump
- Moves up & down when protrude tongue
- Mobile
- Non-tender (BUT may be painful if infected)
- Soft
- Fluctuant
- Key differential= ectopic thyroid tissue
- Management:
- Usually surgically removed to prevent infections
For branchial cysts, discuss:
- What they are
- Presentation
- Management
- Congenital abnormality in which branchial cleft (most commonly second branchial cleft) fails to form properly during fetal development; this leaves a space surrounded by epithelial tissue and this space fills with fluid.
- Presentation usually after 10yrs when cyst more noticeable or infected:
- Lateral, anterior to SCM
- Soft
- Cystic/fluctuant
- Non-tender
- No movement on swallowing
- May see fistula
- Management:
- Conservative- just monitor
- Surgical excision (if recurrent infections, causing other problems etc…)
What is Ludwig’s angina?
What are the features?
Discuss the management
- Progressive cellulitis that invades floor of mouth and soft tissues of neck; most cases occur following teeth infections. Is life-threatening as airway obstruction can occur.
- Features:
- Neck swelling
- Dysphagia
- Fever
- Management:
- Airway management
- IV abx
Summary of neck lumps
When examining a neck lump, what should you look and feel for?
- Location (anterior triangle, posterior triangle or midline)
- Size
- Shape (oval, round or irregular)
- Consistency (hard, soft or rubbery)
- Mobile or tethered to the skin or underlying tissues
- Skin changes (erythema, tethering or ulceration)
- Warmth (e.g., infection)
- Tenderness (e.g., infection)
- Pulsatile (e.g., carotid body tumours)
- Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
- Transilluminate with light (e.g., cystic hygroma – usually in young children)
State some features of lymphadenopathy that suggest malignancy
- Unexplained (e.g., not associated with an infection)
- Persistently enlarged (particularly over 3cm in diameter)
- Abnormal shape (normally oval shaped where the length is more than double the width)
- Hard or “rubbery”
- Non-tender
- Tethered or fixed to the skin or underlying tissues
- Associated symptoms, such as night sweats, weight loss, fatigue or fevers
Discuss the NICE guidelines for 2WW referrals for neck lumps
2WW to head & neck surgeon if:
- There is an unexplained neck lump in a person aged 45 years or older, or
- There is a persistent and unexplained neck lump in a person at any age
Referral for ultrasound:
- In 2 weeks if ≥25yrs and neck lump growing in size
- In 48hrs if <25yrs and neck lump growing in size
What investigations may be done for neck lumps?
Blood tests (the choice of test will depend on the suspected cause):
- FBC and blood film for leukaemia and infection
- HIV test
- Monospot test or EBV antibodies for infectious mononucleosis
- Thyroid function tests for goitre or thyroid nodules
- Antinuclear antibodies for systemic lupus erythematosus
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
Imaging:
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
Biopsy may be required to gain a tissue sample (histology) to establish the exact cause:
- Fine needle aspiration cytology – aspirating cells from the lump using a needle
- Core biopsy – taking a sample of tissue with a thicker needle
- Incision biopsy – cutting out a tissue sample with a scalpel
- Removal of the lump – the entire lump can be removed and examined
State the 4 types of thyroid cancer- ordering most common to least common
- Papillary (70-80%)
- Follicular
- Medullary
- Anaplastic
