neck lumps Flashcards
Cervical Lymphadenopathy definition
• Lymphadenopathy (swelling) of the cervical lymph nodes (glands in the neck)
how common is Cervical Lymphadenopathy
• Common presentation in infection and in malignancy
symptoms of Cervical Lymphadenopathy
INFLAMMATORY:
• Acute, painful, swelling of lymph nodes
• Associated symptoms tonsillitis, pharyngitis or glandular fever
• Occassionaly an abscess can form if the lymph node becomes necrotic
MALIGNANT LYMPHADENOPATHY:
• Mass in the left supraventricular fossa (virchows node) may indicatre metastatic malignancy from a primary tumour below the clavicle (e.g. lungs or upper GI)
• Leukaemia can present with generalised lymphadenopathy
• Pallor, fatigue, fever, persistent infection, bruising and bleeding
signs of Cervical Lymphadenopathy
- Lymphoma can occur at any stage and presents with painless, rubbery lymphadenopathy often in the posterior triangle and sometimes nodes in the axillae and inguinal areas
- Systemic Symptoms fever, night sweats, fatigue and weight loss may occur and hepatomegalu may be an associated finding
DDx for Cervical Lymphadenopathy
- Normal structures
- Skin infections
- Benign tumours
- Malignant primary tumours
- Thyroid lumps
- Salivary gland lumps
- Congenital and developmental lumps carotid body tumours
- Aneurysms
- Trauma
Investigations for Cervical Lymphadenopathy
- Lymph node examination
- If unexplained consider a very urgent FBC
- In people >40, with supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, consider an urgent chest X-ray
Management for Cervical Lymphadenopathy
- Cervical lymphadenopathy thought to be secondary to a viral upper respiratory tract infection — advise medical review if the person becomes systemically unwell, or the swelling persists or has grown after 7 days (may be indicative of non-infective swelling or abscess formation)
- Consider antibiotics for biral, and if not gone in two weeks, urgently refer to ENT
- If malignant, urgent referral
- Consider laryngeal cancer in people aged 45 years and over, particularly if lymphadenopathy is associated with persistent unexplained hoarseness. Refer for an appointment within 2 weeks on an appropriate suspected cancer pathway.
- Consider oral cancer if lymphadenopathy is persistent, particularly if there is also unexplained ulceration in the oral cavity lasting more than 3 weeks. Refer for an appointment within 2 weeks on an appropriate suspected cancer pathway.
Prognosis and complications of Cervical Lymphadenopathy
prognosis and complications dependant on cause
Sialadenitis (Salivary Gland Swelling) definition
- Sialadenitis denotes inflammation and swelling of the parotid, submandibular, sublingual or minor salivary glands
- ACUTE rapid onset of pain and swelling
- CHRONIC intermittent, recurrent episodes of tender swellings
causes of Sialadenitis (Salivary Gland Swelling)
- Initial stage of acute bacterial sialadenitis is characterised by accumulation of bacteria, neutrophils and inspissated fluid in the lumen of ductal structures
- Ductal epithelium damage gives rise to sialodochitis (periductal inflammation), accumulation of neutrophils in the glandular stroma, and subsequent acini necrosis with formation of microabscesses
- Chronic stage is established with recurrent episodes and is characterised by further destruction of salivary acini and the establishment of periductal lymph follicles
- In chronic sclerosing sialadenitis, various degrees of inflammation (ranging from focal lymphocytic sialadenitis to widespread salivary gland cirrhosis with effacement of acini) can result from obstruction of the salivary ducts by microliths, from associated intercurrent infections or from immune reaction with the formation of secondary lymph follicles
- In autoimmune sialadentitis, a response to an unidentified antigen present in the salivary gland parenchyma results in activation of T and B cells that infiltrate the interstititium, with ensuing acini destruction and the formation of epimyoepithelial islands – increases the likelihood of developing B-cell lymphoma
risk factors for Sialadenitis (Salivary Gland Swelling)
- Volume depletion and malnutrition
- Immunosuppression
- Sjogren’s syndrome
- Connective tissue diseases
- Women aged 50-60
- General anaesthesia
- Sialolithiasis
- Chronic mechanical obstruction and/or multiple bouts of acute inflammation
symptoms for Sialadenitis (Salivary Gland Swelling)
- Fever – may accompany an acute infective sialadenitis or autoimmune aetiology suggestive of infection or inflammation
- Pain and dysphagia – usually unilateral, affecting the parotid or submandibular regions, pain may be worse on eating and swallowing
- Facial swelling – usually unilateral and typically over the parotid region, under the tongue or below the jaw, pt may have acute onset and may have had repeated episodes in the past
- Recurrent painful swellings – suggests chronic recurrent sialadenitis
signs for Sialadenitis (Salivary Gland Swelling)
- Exudates of pus from salivary gland opening – indicative of bacterial infection, may occur sponatenously or on manipulation of the gland, stensen’s duct drains the parotid gland opposite the upper second molar tooth, wharton’s duct drsins into the sublingual papillae
- Mandibular trismus – inability to open the mouth to full extent (about 40mm), may be present with large swellings typically of acute bacterial origin
- Cranial nerve palsy ¬– 7, 9 and 12 are at risk of compression
DDx for Sialadenitis (Salivary Gland Swelling)
- Mumps
- Sarcoidosis
- TB
- Parotid and submandibular tumours
- Dental absecess
- Ludwig’s angina
- Angio-oedema
Investigations for Sialadenitis (Salivary Gland Swelling)
• 1st LINE:
- CULTURE AND SENSITIVITIES OF EXUDATE FROM DUCT: bacterial growth on culture if infection is present
- FBC: raised WBC count in the presence of infection, do it if infection is suspected
- FACIAL RADIOGRAPHS (OCCLUSAL AND/OR SOFT TISSUE FILMS): should be done in every pt, sialoliths identified if present
Management for Sialadenitis (Salivary Gland Swelling)
• 1st LINE:
- BROAD-SPECTRUM IV OR ORAL Abx: amoxicillin/co-amoxiclav
- IF LITHIASIS PRESENT: surgery – dependent on what gland is obstructed
o Stones in the intra-oral part of the duct can be removed under general anaesthesia.
o Stones in the submandibular gland are an indication for the removal of the submandibular gland.
o Don’t usually operate on the parotid most parotid gland disease is treated conservatively with sialagogues and intermittent massage of the gland towards the duct.
Prognosis and complications for Sialadenitis (Salivary Gland Swelling)
prognosis - dependant on cause
complications - abscess, dental decay
causes of cervical lymphadenopathy
INFLAMMATORY:
• BACTERIAL CAUSES: acute = B-haemolytic streptococci and staph aureus, chronic = TB
• VIRAL: Epstein-barr virus, Herpes simplex virus, cytomegalovirus and HIV
• PARASITIC: toxoplasmosis and fungal infection
• NON-INFECTIVE: sarcoid and connective tissue disorders, children benign reactive lymph nodes are the most likely cause of neck lump
MALIGNANT LYMPHADENOPATHY:
• Cancer of any part of the body
parotid tumour definition
• Neoplasms formed within the parotid gland tissues
how common is a parotid tumour
- Rare – account for 0.4% of malignancies
* 80% arise in the parotid gland
causes of a parotid tumour
• MALIGNANT:
o Mucoepidermoid Carcinomas: slow growing and mostly start in the parotid glands
o Adenoid Cystic Carcinomas: slow growing but may be difficult to cure because they grow along nerves
o Acinic Cell Carcinomas: more often occur at a younger age and are often slow growing
o Polymorphous Low Grade Adenocarcinomas: mostly curable and start in the minor salivary glands
• PLEIOMORPHIC ADENOMA: 80% of benign parotid tumours, M:F 1:1, peak incidence 30-50yrs old, composed of epithelial cells that form a mucous matrix, grows slowly and has no true capsule so that it can protrude into local tissue, local extension csn be widespread, malignant change may develop in 10-30 yrs
• WARTHIN’S TUMOUR (ADENOLYMPHOMA): usually affects men >50 yrs, benign and presents as a slow growing soft swelling, successfully treated by wide local excision
risk factors for a parotid tumour
- Previous radiotherapy
- Elderly
- Male sex
- Genetics
- Nickel alloy dust and silica
symptoms/signs for a parotid tumour
- Slow growing lump in the infected gland
- Pain
- Anaesthesia (numbness) or trismus (inability to open mouth beyond 40 degrees)
- Asymmetry in the shape of one side of the neck or face
- Facial palsy imply malignancy
DDx for a parotid tumour
- Sialadenitis
* Lithiasis
