Head and Neck Exam 2 Flashcards
Sternocleidomastoid Muscle
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
Anterior Triangle of the Neck
formed by anterior border of the sternocleidomastoid muscle, inferior border of the mandible, and midline of the neck
Posterior Triangle of the Neck
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
Lymph Nodes
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
Lymphadenopathy (LAD)
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
Evaluation of Lymph Nodes
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
Paroid Gland and Preauricular Nodes
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
Posterior Neck Nodes
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
Anterior Neck Nodes
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
Thyroid and Larynx
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
Submanidbular Neck Nodes
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
Taking History
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
Localized Lymphadenopathy
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
Generalized Lymphadenopathy
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
Concern for Malignancy
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
Neck Dissection
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
6 Levels of the Neck
oral cavity cancers: LNs in levels I, II, and III at greatest risk
oropharyngeal cancers: levels II, III, and IV
thyroid cancers: level VI
Radial Neck Dissection
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)
Modified Neck Dissection
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)
Selective Neck Dissection
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)
Sublevel 1A
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
Sublevel 1B
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
Midline Neck Anatomy
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
Visual Inspection of Neck
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
Brachial Cleft Cysts
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
Thyroglossal Duct Cysts
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
Ranula
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”
Neoplastic Neck Mass
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
Unilateral Swelling of Parotid Gland
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
Bilateral Parotid Enlargement
“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
Bilateral Parotid Enlargement: Common Causes
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
Bilateral Parotid Enlargement: Infectious Causes
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)
Bilateral Parotid Enlargement: Autoimmune Causes
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
