Neck Lesions Flashcards
What is an important aspect to consider when examining neck masses in children?
It is important to determine whether the mass is located in the anterior midline or laterally.
What anatomical structure divides the neck into anterior and posterior triangles?
The sternocleidomastoid muscle divides the neck into anterior and posterior triangles.
What are the two systems that can be used when examining the neck?
1) Anatomical landmarks, and 2) Etiological classification (infectious, inflammatory, systemic, autoimmune, congenital, neoplastic, trauma-related).
What should be the approach when examining the neck?
The examination should be systematic, utilizing anatomical landmarks or an etiological classification system.
How are the salivary glands classified?
The salivary glands are classified into major and minor glands. Major glands include the parotid (serous), sublingual (mucinous), and submandibular (mixed) glands.
Where does the parotid duct (Stensen’s duct) open?
The parotid duct opens opposite the second maxillary molar.
What is the relationship between the parotid gland and the facial nerve?
The facial nerve runs between the superficial and deep lobes of the parotid gland.
Where does the submandibular duct (Wharton’s duct) open?
The submandibular duct opens into the floor of the mouth, just lateral to the lingual frenulum.
What are the ducts of the sublingual gland called?
The sublingual gland has numerous ducts called Rivinus’ ducts, which open into the floor of the mouth.
What nerve is in close proximity to the sublingual gland?
The lingual nerve is in close proximity to the sublingual gland.
What is the daily saliva secretion in adults, and which gland secretes the most?
The salivary glands secrete 1-1.5 liters of saliva per day, with 70% being secreted by the submandibular gland.
What are the functions of saliva?
The functions of saliva include lubrication of the mouth, oral and dental hygiene (through buffers, antibodies, and lysozymes), moistening of orally ingested material, dissolving chemicals that aid with taste, and initiating digestion.
Are salivary gland conditions common in the pediatric population?
No, salivary gland conditions are uncommon in children. The majority of lesions are lymphaticovenous malformations.
What systemic conditions often involve salivary glands in children?
Salivary glands are frequently involved in systemic conditions, though the specific conditions may vary.
What should be noted when evaluating a salivary gland lesion in terms of its presentation?
It is important to note whether the lesion is unilateral or bilateral and any association with eating.
What is a ranula?
A ranula is a mucous extravasation of the sublingual gland that forms a cyst in the floor of the mouth
What is a plunging ranula?
A plunging ranula occurs when the cyst extends through the myelohyoid muscle.
What are some benign neoplasms of the salivary glands?
Benign lesions include lymphatic malformations, haemangiomas, and pleomorphic adenomas.
What are some malignant salivary gland neoplasms?
Malignant lesions include Mucoepidermoid Carcinoma, Adenoid cystic carcinoma, and Rhabdomyosarcoma.
Where do most salivary gland neoplasms occur in children?
More than 90% of neoplasms in children occur in the parotid gland
What should a physical examination include when assessing a salivary gland condition?
The physical examination should include evaluation of the inside of the mouth and the contralateral side of the neck.
What features suggest a non-benign salivary gland lesion?
Features that suggest a non-benign lesion include firm, fixed lesions that are often not tender.
What diagnostic methods can be used to evaluate salivary gland conditions?
Diagnostic methods include Ultrasonography, Computer Tomography (CT), and Magnetic Resonance Imaging (MRI).
How can a tissue specimen be obtained for diagnosis of salivary gland lesions?
A tissue specimen can be obtained via fine needle aspiration, trucut biopsy, or an open incision/excision biopsy technique.
How can sialadenitis be classified?
Sialadenitis can be classified into viral (CMV, EBV, HIV, Mumps), bacterial (Staph, Strep), or chronic (obstructive from stones or non-obstructive, associated with systemic conditions such as sarcoidosis, tuberculosis, or Sjögren’s syndrome).
What is the treatment for abscess formation in sialadenitis?
In cases of abscess formation, careful incision and drainage or aspiration is indicated.
How is sialithiasis treated?
Sialithiasis can be treated conservatively or with incision of the ductal orifice. In rare recalcitrant cases, the entire gland may need to be excised.
How is a ranula treated?
Treatment for a ranula can range from simple marsupialization to complete excision of the gland.
What is the treatment for pleomorphic adenomas?
Pleomorphic adenomas are treated with excision, usually involving the superficial lobe only.
How are non-benign lesions of the salivary glands treated?
Non-benign lesions are treated according to oncological principles.
What areas should be thoroughly examined when assessing lymph nodes in the cervical region?
The areas that drain to cervical lymph nodes include the ears, nose and throat, scalp, upper limbs, and thyroid gland.
How common is lymphadenopathy in children?
Lymphadenopathy is common in children.
How can you distinguish between lymphadenopathy that needs further investigation and self-limiting cases?
Lymph nodes that are more than 1-2 cm, firm, fixed, located in the supra-clavicular area or posterior triangle, or persist for more than 4-6 weeks, should be investigated or closely observed.
What is the significance of persistent lymphadenopathy lasting more than 4-6 weeks?
Persistent lymphadenopathy lasting more than 4-6 weeks warrants investigation.
What are the two main reasons for lymph node enlargement?
Enlarged lymph nodes can be reactive to infections or injury within their drainage area or have standalone pathology.
What infections commonly cause lymphadenopathy in children?
Common infections include tuberculosis, HIV, EBV, CMV, and bacterial lymphadenitis.
What are some neoplastic conditions that can cause lymphadenopathy?
Neoplastic conditions include lymphoma, leukemia, neuroblastoma, and rhabdomyosarcoma.
What important history questions should be asked when evaluating lymphadenopathy?
Important questions include the duration, size, and site of the lymphadenopathy, presence of traumatic/infected lesions, systemic symptoms, and whether the lymphadenopathy is generalized or localized.
What imaging modalities can help evaluate lymphadenopathy?
Ultrasonography can assess lymph node morphology, and chest X-ray (CXR) can investigate TB or mediastinal masses.
What basic blood tests are useful in the diagnostic workup of lymphadenopathy?
Basic blood tests include a full blood count, smear, LDH, and infectious markers
How can a tissue sample be obtained for diagnosis of lymphadenopathy?
Tissue samples can be obtained via fine needle aspiration or an open biopsy (incisional or excisional).
What does further treatment of lymphadenopathy depend on?
Treatment depends on the underlying condition diagnosed.
What is the general approach to treating lymphadenopathy?
Treatment is mostly medical, but in cases of malignancy, it may involve surgery after neoadjuvant chemotherapy and radiotherapy.
What is the surgical treatment for lymphadenitis?
Surgical treatment includes drainage of any abscess formation and obtaining tissue for diagnostic purposes.
What is the anatomical structure of the thyroid gland?
The thyroid consists of two lobes joined by an isthmus and lies in the anterior midline of the neck, from C5 to T1.
Where does the thyroid gland originate embryologically?
The thyroid gland originates from a primordium located at the posterior base of the tongue (Foramen Cecum).
How does the thyroid gland reach its normal position during development?
The thyroid migrates down the neck to its customary position.
What is the thyroglossal duct, and when does it normally obliterate
The thyroglossal duct is a transient connection between the thyroid gland and the base of the tongue, and it normally obliterates by 7 weeks of gestation.
What happens if the thyroglossal duct fails to obliterate?
If the thyroglossal duct fails to obliterate, it can result in a thyroglossal duct cyst.
What is one of the most common thyroid conditions seen in the pediatric population?
A thyroglossal duct cyst.
How does a thyroglossal duct cyst typically present?
It usually presents as a midline neck mass that classically moves upwards with protrusion of the tongue.
What may develop if a thyroglossal duct cyst becomes infected?
A draining sinus may form.
Are all thyroglossal duct cysts located in the midline?
No, up to 40% of thyroglossal duct cysts may be located off the midline.
What symptom might a patient report if the thyroglossal duct cyst communicates with the oral cavity?
The patient may report a foul taste in their mouth.
What other thyroid conditions should be considered when evaluating a thyroid mass?
Thyroid nodules, goitre, and thyroiditis.
Why is it important to work up pediatric thyroid nodules carefully?
Although rare in children, thyroid nodules have a higher incidence of malignancy compared to adults.
What is a differential diagnosis for a small, mobile, firm central neck mass present since birth?
A dermoid cyst.
How can a dermoid cyst be distinguished from a thyroglossal duct cyst on examination?
A dermoid cyst does not move on protrusion of the tongue.
How is the diagnosis of a thyroglossal duct cyst primarily made?
The diagnosis is based on a thorough history and physical examination.
What imaging modality can aid in the diagnosis of a thyroglossal duct cyst?
Ultrasonography
How is the final confirmation of a thyroglossal duct cyst made?
Final confirmation is obtained from histology after lesion excision.
Why do some centers routinely screen for normal thyroid tissue in patients with a thyroglossal duct cyst?
In rare cases, the cyst may contain the only functioning thyroid tissue the patient has.
Why is surgical management recommended for thyroglossal duct cysts?
There is a small risk of malignant transformation.
What additional diagnostic methods are used for other thyroid conditions?
Serum thyroid function tests, nuclear scintigraphy, and fine needle aspiration.
How should infected thyroglossal duct cysts be treated initially?
Infected cysts should be treated with needle aspiration and appropriate antibiotics.
Why should incision and drainage of an infected thyroglossal duct cyst be avoided?
Incision and drainage should be avoided as it may complicate subsequent surgery.
What is the definitive surgical management for a thyroglossal duct cyst?
The Sistrunk procedure, which includes excision of the central portion of the hyoid bone.
When should surgery for a thyroglossal duct cyst be performed?
Surgery should be undertaken when there is no active infection.
Why is it important to perform definitive surgery sooner rather than later in cases of recurrent infections?
Repeated infections increase the risk of recurrence, so early definitive surgery minimizes this risk.
What should be done with the excised specimen after the Sistrunk procedure?
The specimen should be sent for histological confirmation.
What causes branchial arch anomalies?
They result from the failure of complete resorption of primitive branchial apparatus structures.
How can branchial arch anomalies present?
They can present as cysts, cartilaginous remnants, sinuses, or fistulae.
Which branchial arch anomaly is the most common?
Second arch anomalies are the most common.
What is the difference between a cyst, a fistula, and a sinus tract in branchial arch anomalies?
• Cyst: Lined by epithelium without an external opening.
• Fistula: Has both an internal and external communicating opening.
• Sinus Tract: Has either an internal or external opening.
How do branchial arch anomalies typically present?
They present as lateral neck masses, often between the anterior lower half of the sternocleidomastoid muscle and the ipsilateral tonsillar fossa.
What percentage of branchial arch anomalies may be bilateral
About 10% may be bilateral
What important structures are closely associated with the tract of second branchial arch anomalies?
The glossopharyngeal and hypoglossal nerves, as well as the carotid sheath.
What should be considered if branchial arch anomalies are associated with pre-auricular pits?
Syndromes with renal, eye, and ear anomalies should be considered.
How is the diagnosis of branchial arch anomalies usually made?
Diagnosis is mostly made on history and physical examination, but radiographic imaging may be helpful in uncertain cases.
What is the definitive treatment for branchial arch anomalies?
Surgical excision.
What technique may be needed during surgery to access the most cephalad part of the lesion?
A stepladder incision.
Why is complete excision important in the treatment of branchial arch anomalies?
Complete excision minimizes the risk of recurrence.
What must be preserved during the surgical excision of branchial arch anomalies?
All vital structures that lie in close proximity to the lesion.
What is essential for surgeons treating branchial arch anomalies?
A thorough knowledge of embryology and anatomy.
What muscle is involved in fibromatosis coli?
The sternocleidomastoid muscle.
What are the superior and inferior attachments of the sternocleidomastoid muscle?
• Superior attachment: Superior nuchal line and mastoid process.
• Inferior attachments: Sternum and clavicle.
What is the basic pathology underlying fibromatosis coli?
Replacement of normal muscle with fibrous tissue.
Why is the term “sternocleidomastoid tumor” misleading?
Because fibromatosis coli is not a neoplasm.
How does fibromatosis coli typically present?
With torticollis and a painless swelling within the sternocleidomastoid muscle.
When does fibromatosis coli usually become evident?
About 3 weeks after birth.
What is fibromatosis coli often associated with?
Traumatic delivery.
How is the diagnosis of fibromatosis coli usually made?
Clinically, and confirmed with ultrasound.
What other conditions should be ruled out when diagnosing fibromatosis coli?
Other causes of torticollis, especially atlantoaxial pathology and posterior fossa tumors.
What is the primary treatment for fibromatosis coli?
Conservative management.
What therapy may aid in the resolution of fibromatosis coli?
Physiotherapy
When is surgical intervention indicated for fibromatosis coli?
If the condition persists beyond a year or if signs of hemifacial hypoplasia or plagiocephaly develop.
What does the surgical treatment of fibromatosis coli involve?
Surgical division of the sternocleidomastoid muscle.
What are the two types of sebaceous cysts?
Dermoid and epidermoid lesions.
What distinguishes dermoid cysts from epidermoid cysts?
Dermoid cysts contain accessory glandular structures like hair follicles and papillae.
What is the main content of sebaceous cysts?
Sebaceous material, which may become secondarily infected.
What are the possible causes of sebaceous cysts?
• Entrapment of mesodermal and endodermal elements during fusion of the anterior branchial arches.
• Failure to separate from the neural tube.
How are sebaceous cysts typically diagnosed?
• Lesions are usually midline and well-circumscribed.
• The overlying skin may be adherent to the lesion.
• Ultrasound may be helpful in distinguishing them from other cervical masses.
Why is imaging sometimes recommended for midline lesions of the face and scalp suspected to be sebaceous cysts?
Because sebaceous cysts occasionally have intracranial extension.
What is the treatment for sebaceous cysts?
Complete excision without rupture of the capsule to minimize the risk of recurrence.
What causes a cervical midline cleft?
Failure of fusion of the first and second branchial arches.
How does a cervical midline cleft typically present?
• Midline lesion with thin, atrophic skin.
• Nipple-like skin tag at the cephalad end.
• Tiny sinus tract at the caudal end.
What is the treatment for a cervical midline cleft?
Early complete excision and closure of the wound with serial Z-plasties or a similar cosmetic technique to prevent contracture of the scar.
Where is a thymic cyst typically found?
It is typically found in the anterior triangle of the neck (more commonly on the left) but may also be located in the chest or mediastinum.
What characteristic sign can be observed with a thymic cyst during physical examination?
The cyst enlarges with a Valsalva maneuver.
How is the diagnosis of a thymic cyst usually made?
The diagnosis is usually made on histology after excision of the cervical lesion.
Does a thymic cyst have malignant potential?
No, thymic cysts have no malignancy potential.
What is the treatment for a thymic cyst?
Surgical excision is curative. Care must be taken to avoid injury to neurovascular structures during the procedure.
What are some primary causes of neck neoplastic lesions?
Primary cervical organs such as thyroid carcinoma or rhabdomyosarcoma.
How can neck neoplasms be related to metastasis?
Neck masses can be a manifestation of local metastasis from organs draining into cervical nodal basins, or distant metastasis from solid organ malignancies (e.g., liver or kidney).
What are some systemic malignancies that can manifest as neck masses?
Lymphoma and leukaemia.
What are some danger signs or red flags that suggest a neck mass may be malignant?
• Weight loss and failure to thrive
• Unexplained fever
• Malaise
• Anaemia
• A new limp
• Proptosis
• Raccoon eyes
• Cranial nerve palsy
• Hypertension
• Haematuria
• Previous malignancies and radiation treatment
• Significant family history
• Lymph nodes that are fixed, painless, persistent (more than 6 weeks), and >2 cm.
