Head and Neck Exam 2

Question 1

Sternocleidomastoid Muscle

Answer 1

divides the neck into anterior and posterior triangles

landmark to palpate lymph nodes during a head and neck exam

deep to this muscle run the carotid artery and internal jugular vein

over the surface of this muscle runs the external jugular vein

Question 2

Anterior Triangle of the Neck

Answer 2

formed by anterior border of the sternocleidomastoid muscle, inferior border of the mandible, and midline of the neck

Question 3

Posterior Triangle of the Neck

Answer 3

bounded by the middle third of the clavicle inferiorly, the trapezius muscle posteriorly,, and the posterior border of the sternocleidomastoid muscle anteriorly

inferior belly of the omohyoid muscle crosses the inferior part of the triangle
-can be mistake for lymph node or mass

Question 4

Lymph Nodes

Answer 4

bean-shaped, encapsulated, and highly organized structures

located along larger vessels of lymph-vascular system

primary sit to stimulate immune response to antigens in lymph

human body has about 450

grouped in areas where lymphatics convert to form larger trunks
-neck, axillae, groin, lung hila, mesentery of the bowel, and para-aortic areas

Question 5

Lymphadenopathy (LAD)

Answer 5

lymph nodes that are abnormal in size and consistency

 - normal: 1 cm diameter
 - larger the node, more serious the underlying cause (3-4 cm diameter very worrisome)

physical exam of size is only marginally accurate (need imaging)

site of involvement is important - infection and carcinoma are likely to cause LAD in lymphatic drainage of the site of the disorder

LNs with metastatic carcinoma are rock hard

LNs containing lymphoma are firm and rubbery

LNs enlarged in response to infection are soft/tender

Question 6

Evaluation of Lymph Nodes

Answer 6

symmetry from left to right sides is helpful in distinguishing enlarged nodes

drainage basin of effected nodes should be examined for lesions

 - cat scratch disease 
 - gardening (Sporotrichosis)

greater node size, greater percentage of it being cancer

abnormal nodes can become fixed to adjacent tissues by invading cancers or inflammation in tissue surrounding nodes

 - can also become fixed to each other (matted) 
 - normal nodes are movable

Question 7

Paroid Gland and Preauricular Nodes

Answer 7

these nodes by ears

feel parotid bilaterally and the preauricular nodes

compare symmetry, identify nodes by size and if hard or soft, painful or painless, and freely movable or fixed

possible findings: lymph nodes may have nodules, swelling and/or masses

Question 8

Posterior Neck Nodes

Answer 8

nodes in this category:

 - posterior auricular 
 - occipital  * **to palpate these, drop head forward to enhance access 

palpate over trapezius for the spinal accessory and posterior cervical nodes

Question 9

Anterior Neck Nodes

Answer 9

nodes in this category:

 - jugular chain 
 - deep cervical nodes 
 - superficial cervical nodes  * **to palpate, place fingers firmly on both sides of sternocleidomastoid muscle from its origin at the clavicle to insertion at the mastoid process behind ear 

palpate supraclavicular nodes above clavicles and near inferior midline of neck

compare for symmetry and identity nodes for size, consistency, level of pain, or if freely movable of fixed

Question 10

Thyroid and Larynx

Answer 10

visually inspect and bimanually palpate thyroid

 - compare lobes for sym
 - normally difficult to palate 

palpate larynx while patient swallows
-inspect for enlargement or mobility; listen for hoarseness

Question 11

Submanidbular Neck Nodes

Answer 11

to palpate submandibular and submental nodes have patient lower chin and manually palpate directly underneath china and medial side of mandible

grasp and roll tissue over bone edge of mandible, anteriorly and bilaterally

Question 12

Taking History

Answer 12

history and physical exam can lead to differential diagnosis of peripheral lymphadenopathy

localizing signs or symptoms suggesting infection of malignancy

constitutional symptoms such as fever, night sweats, or weight loss suggesting TB, lymphoma, or other malignancy
-fever usually accompanies LAD for the majority of infectious etiologies

use of certain meds can lead to LAD

foreign travel extends differential diagnosis to diseases that would not otherwise occur locally

Question 13

Localized Lymphadenopathy

Answer 13

anterior cervical lymph nodes often enlarged bc of one of a variety of infections

reactive viral LAD is most common cause of cervical LAD, especially in kids
-typical viral infections cause symptoms for 1-2 weeks and LAD generally resolves in 1-2 weeks

infection with Mycobacterium tuberculosis is suggested when multiple enlarged cervical nodes develop over weeks to months
-become fluctuant or matted without inflammation or tenderness

infection with Bartonella henselae (cat scratch disease)

 - multiple enlarged cervical lymph nodes
 - quite painful and accompanied by fevers and generalized malaise

Question 14

Generalized Lymphadenopathy

Answer 14

may be feature of systemic diseases, which may be recognized by other clinical findings

HIV infection LAD common in primary HIV infection

 - primarily involves axillary, cervical, and occipital nodes 
 - develops during 2nd week of acute symptomatic HIV infection 

classic infectious mononucleosis characterized by triad of moderate to high fever, pharyngitis, and lymphadenopathy

 - lymph node involvement is typically symmetric and involves posterior cervical more than anterior chain 
 - LAD may also be present in axillary and inguinal areas, which helps to distinguish mono from other causes of pharyngitis 
 - LAD peaks in first week, then subsides over 3 weeks

Also..
systemic lupus erythematosus (SLE), medications, and sarcoidosis

Question 15

Concern for Malignancy

Answer 15

hard cervical nodes, particularly in older patients and smokers, suggest metastatic head and neck cancer
-in patients with LAD, probability of underlying carcinoma increases rapidly with age

metastatic nodes in posterior triangle often related to nasopharyngeal carcinoma

nodes alone upper jugular chain drain from oral cavity, oropharynx, and larynx

supraclavicular nodes should raise concerns for tracheobronchial, distal esophageal, or a stomach carcinoma

patients with either Hodgkin or non-Hodgkin lymphoma may present with painless, firm, and peripheral LAD

Question 16

Neck Dissection

Answer 16

surgical procedure designed to remove metastatic cancer that involves the cervical lymph nodes
-patients with positive lymph nodes more likely to have recurrences and poorer prognosis

may be electively performed even in absence of clinical or radiology evidence
-dont when likelihood of microscopic lymphatic metastasis is very high

Question 17

6 Levels of the Neck

Answer 17

oral cavity cancers: LNs in levels I, II, and III at greatest risk

oropharyngeal cancers: levels II, III, and IV

thyroid cancers: level VI

Question 18

Radial Neck Dissection

Answer 18

all lymph nodes levels are removed along with non-lymph node structures (final accessory nerve, internal jugular vein, and sternocleidomastoid muscle)

for clinically positive lymph nodes (levels I-V)

Question 19

Modified Neck Dissection

Answer 19

all lymph nodes removed like in a radical, except 1 or more non-lymphatic structures are preserved

for clinically positive lymph nodes (levels I-V)

Question 20

Selective Neck Dissection

Answer 20

preservation of 1 or more lymph node groups that are routinely removed in radial neck dissection

for those with no positive clinical lymph nodes (levels I-III)

Question 21

Sublevel 1A

Answer 21

nodes are at greatest risk of harboring metastases from cancers that raise in FOM, anterior oral tongue, anterior mandibular alveolar ridge, and lower lip

many tumors of the head and neck do not metastasize to level 1A

Question 22

Sublevel 1B

Answer 22

nodes are at greatest risk for harboring metastases from cancers that arise from oral cavity, anterior nasal cavity, and soft tissue structures of the mid face and the submandibular gland

Question 23

Midline Neck Anatomy

Answer 23

thyroid gland: H-shaped organ that has 2 lateral lobes joined by an isthmus
-isthmus is at the level of the second and third tracheal rings

lateral lobes curve posteriorly around sides of trachea and esophagus
-each is ~ 4-5 cm long
top of each lobe is level with lower border of thyroid cartilage

Question 24

Visual Inspection of Neck

Answer 24

inspect trachea for any deviation from midline position

place finger along one side of trachea and note space between it and sternocleidomastoid muscle
-compare with other side for sym.

tip patient’s head back, using tangential lighting directed downward for tip of chin, inspect region below cricoid cartilage and identify contours of gland
-very hard to do

observe patient swallowing

 - watch for upward movement of thyroid 
 - notice contour and sym.  * **thyroid cartilage, cricoid cartilage, and thyroid gland all rise with swelling and then fall to resting positions

Question 25

Brachial Cleft Cysts

Answer 25

account for almost 20% pediatric neck masses

usually present in late childhood or early adulthood when previously unrecognized cyst becomes infected

almsot always anterior to the sternocleidomastoid muscle

Question 26

Thyroglossal Duct Cysts

Answer 26

present as midline mass in anterior neck

often asymptomatic until they become infected in setting of upper respiratory tract infection

usually diagnosed in childhood but up to 40% may present after age 20

Question 27

Ranula

Answer 27

mucocele or retention cyst arising from obstruction in sublingual glands in FOM

obstructed gland leads to pseudocyst formation due to mucous extravasation

often painless and slow-growing

when extend through mylohyoid muscle in neck, referred to as “plunging ranula”

Question 28

Neoplastic Neck Mass

Answer 28

predominately related to metastatic squamous cell carcinoma uprising fro the aerodigestive tract

primary thyroid tumor will usually present as mass in anterior neck
-while majority are benign, malignancy must be considered

neck involved lymphoma very common in children with Hodgkin disease (HD)
-found in up to 80% of patients

***HD should be suspected if patient has history of fever, night sweats, chills, and diffuse LAD

Question 29

Unilateral Swelling of Parotid Gland

Answer 29

most often due to infected parotid duct

acute suppurative parotitis likely develops from ascending ductal infection, facilitated by dehydration, that originates from oral bacterial gathering around gland

seen in newborn infant, debilitated patient’s, and systemically ill patient recovering from abdominal surgery (inadequate fluid replacement)

onset swelling rapid

pain can be severe

pus can be observed coming out of duct

Question 30

Bilateral Parotid Enlargement

Answer 30

“Sialadenosis”: bilateral persistent, painless, soft, non-neoplastic, non-inflammatory swelling

parotid glands do NOT flute in size in associate with meals

blood chemistry studies can be helpful to determine liver dysfunction, diabetes, or abnormalities associated with malnutrition

Question 31

Bilateral Parotid Enlargement: Common Causes

Answer 31

alcoholism: most common cause (seen in 30-80% patients with cirrhotic livers)

untreated diabetes mellitus

malnutrition

 - seen in 10-66% bulimia patients 
 - "Russell's sign": calluses on back of knuckles

Question 32

Bilateral Parotid Enlargement: Infectious Causes

Answer 32

viral mumps: acute contagious disease that affects primarily children under age 15

 - caused by Paramyxovirus 
 - before englargment, symptoms include fever, headache, myalgia, and malaise 

HIV: persistent, painless parotid enlargement occurs in 5% of patients
-patients with bilateral enlargement and HIV are in subset known as DILS (diffuse infiltrative CD8 lymphocytosis syndrome)

Question 33

Bilateral Parotid Enlargement: Autoimmune Causes

Answer 33

Sjogren sydrome: chronic autoimmune disease characterized by lymphocytes that destroy exocrine glands, primarily lacrimal and salivary glands

bilateral parotid gland swellings develop and multiple systemic organs can be involved

labial minor salivary gland biopsy
-see a lot of inflammatory cells in salivary glands

a symptom: dry eyes