Neck Lumps + H&N cancer Flashcards
What causes a branchial cyst
Remnant of fusion failure of branchial arches or lymph node cyst degeneration - 3,4,5
BENIGN
How does it become infected
May form fistula
Typically following resp infection
Becomes infected and enlarges
How do you deal with infection
Excise to prevent further infection
How does branchial cyst present and where
Late childhood - early adulthood - 3rd decade Asymptomatic neck lump Lateral and anterior to SCM at junction between upper and middle third Unilateral Slowly enlarging Smooth, soft, fluctuant Non-tender No movement on swallow No transillumination
How do you Dx / any neck lump
What does FNA show for brachial
Need to exclude malignancy - Esp if >40 - All cystic lumps = malignancy till proven otherwise USS - doesn't show Refer to ENT FNA - shows acellular fluid + crystals
How do you Rx
Excision
Ax if acute infection
What are Ddx of neck lump
Congenital Branchial cyst Thyroglossal cyst Dermoid cyst - midline and <20 Cystic hygroma - infancy and lymph aspirated due to malformation in lymphatic system (posterior, soft, non-tender and transilluminates) - risk of haemorrhage / infection and can interfere with feeding and breathing Rx = aspiration or surgery Vascular malformation
Infection
Reactive LN = most common (consider TB, HIV, EBV, chronic infections(
Neck abscess = emergency
Salivary gland infection
Other / malignancy Pharyngeal pouch TB Lymphoma - HSM Thyroid tumour Salivary gland tumour Cervical rib - thoracic outlet Carotid aneurysm - pulsatile and doesn't move on protrusion
What is an emergency
Neck abscess
What does a lymphoma tend to be
Rubbery
Painless
Associated splenomegaly
Weight loss
How does carotid aneurysm present
Pulsatile lateral neck mass
Doesn’t move on swallowing
Levels of LN in neck
1 = submental and mandibular 2,3,4 = down sternocleidmastoid
5 = posterior triangle
6 - around hyoid
What does painful LN suggest
Infective
Reactive
What does painless LN suggest
Malignancy
How do malignant LN present
Round Firm / hard Irregular Craggy Fixed Non-tender Rapidly enlarged Lymphoedema
What is important in Hx of neck lumps
How long - <3 weeks = likely reactive Where in neck - Intradermal suggest lipoma or sebaceous cyst Fluctuation - Has it changed in size - Does it come and go H+N symtpoms - Is it painful - Any sore throat / cough / cold - Hoarse voice - Difficulties or painful swallow - Any breathing issue - Any weight change - Any ear pain - Any blood B symptoms - Fever / night sweat / weight loss
PMH - Investigation or Rx of lump - Hx head or neck RT DH and allergies SH - Smokin - Alcohol - Foreign travel
What do you look on examination
Site Size Shape - irregular or regular Sore Attached to skin / fixed Soft or hard
Does it move on swallow
What are common symptoms in head and neck
Sore throat Dysphonia / hoarse - worry if persistant Dysphagia Odynophagia Mouth or throat ulcer Neck lump Otalgia Airway issue / stridor Blood Snoring
What produces a bruit on auscultation
Grave’s
Carotid bruit
What cells do head and neck cancers tend to affect and where
SCC = majority Mouth / nose / throat Oral cavity Pharyn / larynx Salivary glands - rare
What are the symptoms
Neck lump Hoarse voice Persistent sore throat Persistent mouth ulcer - often painless Mouth numbness Mouth bleeding Sore tongue Patches in the mouth Earache / effusion Dysphagia
What are RF
>40 Smoking Alcohol HPV 16+18 in oropharynx EBV in nasopharynx GORD Salted food Poor oral health Occupation Radiation / sun exposure FH Immunosuppression
What are symptoms of oral cavity cancer (lip, gums, tongue)
White or red patch Painless ulcer or lump - non healing Non-healing ulcer Unusual bleeding Red / erythematous mucous membrane = strong association with malignancy Pain = late Sx Swollen jaw / neck lump if mets
What are symptoms of pharynx cancer (oropharynx + hypopharnx)
Trouble breathing Trouble speaking Dysphagia Pain in neck or throat Painless tonsillar swelling Referred otalgia Trismus = red flag for infiltration Headache Ringing in ears
What are sinus Sx of head and neck cancer
Blocked sinus Chronic infection Nose bleed Swollen eyes Pain in teeth
What are symptoms of salivary gland cancer
80% = in parotid 80% = pleomorphic adenoma (benign)
Sx Swelling under chin Hard fixed mass - painful Numbness Paralysis of muscles in the face - facial nerve = suggests malignancy Pain in face or neck LN involvement
Red flag
- Hard
- Rapid
- Tender
- Infiltrating surrounding structure / skin
- Facial weakness
When would you refer under the suspected cancer pathway
45+ with persistent unexplained hoarseness or lump in neck
Unexplained ulceration in oral cavity 3+ weeks
Lump on lip in oral cavity
Red or white patch in oral cavity consistent with erythroplakia
Unexplained thyroid lump
Dysphagia
How do you Dx
Refer ENT Biopsy / FNA Endoscopy Physical exam Imaging - MRI for tumour margins - CT for spread
How do you Rx
Surgery
Radiation
Chemotherapy
Targeted therapy
What is associated with nasopharyngeal cancer (SCC)
EBV
Asian smoked fish
How does it present
Cervical LN Otalgia Unilateral serous otitis media - refer if not related to URTI Obstruction Discharge Headache Epistaxis Tinnitus Conductive hearing loss from otitis media Blood in sputum Ear fullness CN palsy
How do you Dx
Detailed head and neck exam Nasa-Endoscopy + biopsy FNA of neck nodes CT - better for bony MRI - better for soft tissue
How do you Rx
RT = 1st line
Combined chemo + RT
What are differential for swollen salivary glands
- Parotid
- Submandibular
- Sublinqual
Tumour Infection - Parotiditis / HIV Autoimmune - Sjogren / Sarcoid Acute viral- Mumps Ductus calculus - stone
How does ductus calculus (stone in duct) present
Recurrent unilateral pain and swelling on eating
Stone may be palpable
Can become infected leading to chronic
Where is most common and how do you Dx and Rx
80% = submandibular
X-ray
Surgical removal
How do benign salivary gland tumours (Adenoma) present
80% = parotid
DO NOT invade strutures e.g. facial nerve
How do you Dx tumour
X-ray to exclude calculi FNAC in most If malignancy = parotidectomy = diagnostic and therapeutic CT / MRI to stage Lymphoma needs biopsy
What do you include
Facial nerve if involved
What does HIV cause in parotid gland
Bilateral multi cystic symmetrical swelling
What does Sjogren cause
Bilateral non-tender enlarement
What does sarcoid cause
Non-tender bilateral
Facial nerve palsy
What should patient get if urgent referral for H+N cancer
CXR to exclude apical lung lesion
When is infection common
Elderly
Dehydration
Poor oral hygiene
What are the symptoms
Painful diffuse swelling of gland
Fever
Pus leaking from duct
How do you Rx
Antibiotics
Oral hygiene
Surgical drainage may be required
If lump in anterior triangle
Branchial cyst
Parotid tumour
Carotid artery aneurysm
If posterior triangle
Cervical rib C& Pharyngeal pouch Cystic hygroma- usually infant and transilluminate bright Pancoast tumour Subclavian artery aneurysm
What are red flags in head and neck that get urgent referral
Unexplained lump change over 3-6 months Hoarse voice >3 weeks New onset dysphagai Unexplained persistent swelling salivary gland Otalgia >4 weeks + normal otoscopy Unexplained persistent or sore throat Non-healing ulcer White or red lesion in mouth or oropharynx Any B Sx Unexplained tooth loosening
Pathology of neck lumps in order of LN regions
1
- Submandibular gland pathology
- Tooth abscess
2
- Parotid pathology
- Brachial cyst
- LN (benign or malignant)
3
- Brachial cyst
- Paraganglioma
- LN
4
- LN
5
- Cystic hygroma
- LN
6
- Thyroid goitre
- Thyroglossal cyst
- Dermoid and epidermal cyst
