Neck Masses Flashcards
Borders of the anterior triangle of the neck?
Superiorly– inferior border of the mandible (jawbone).
Laterally– anterior border of the sternocleidomastoid.
Medially– sagittal line down the midline of the neck
Borders of the posterior triangle of the neck?
Anterior– posterior border of the sternocleidomastoid.
Posterior– anterior border of the trapezius muscle.
Inferior– middle 1/3 of the clavicle
What is a thyroglossal duct cyst?
Well circumscribed midline neck mass, moves with protrusion of tongue
Part or all of the thyroglossal duct fails to disappear and remain patent.
Frequently near hyoid bone
Epidemiology of tyroglossal duct cyst?
Commonest
Usually age 0-5yrs
Clinical presentation of TDC?
Asymptomatic, but bothersome.
Complications of TDC?
infected by oral flora, can form sinus
Treatment for TDC?
Sistrunk procedure (excision of entirety of the cyst and duct and midpoint of the hyoid bone)
What is brachial cleft cyst?
Remnants of the embryological second branchial cleft or cervical sinus
Epidemiology of brachial cleft cyst?
20% of pediatric neck masses
Describe the brachial cleft cyst?
Painless, firm mass lateral to midline, usually anterior to the sternocleidomastoid muscle, which does not move with swallowing.
Diagnosing a Brachial cleft cyst?
Usually diagnosed in late childhood/adulthood after previously undiagnosed cyst becomes infected
Often a history of preceding upper respiratory infection.
Treatment of BCC?
complete surgical excision of both the cyst and any associated tracts
Complications of BCC?
infection of the cyst, tract, or sinus with possible abscess formation
What is a cystic hygroma?
Congenital malformation consisting of cyst-like cavities containing lymph.
Associated with fetal aneuploidy (e.g., Turner syndrome, trisomy 21), and anatomical malformations (e.g., congenital heart defects).
Describe a cystic hygroma?
Soft, compressible, painless neck mass, classically found in the posterior triangle of the neck.
Diagnostics and clinical features of cystic hygroma?
Can cause dysphagia or airway compromise
Can be transilluminated
Treatment of cystic hygroma?
Small masses may regress spontaneously, but surgical excision is indicated to prevent infection of the mass or airway compromise.
What is a pharyngeal diverticulum/pouch?
a pharyngeal pouch that forms where the lower part of the throat and the upper part of the esophagus meet
- Arises as a pulsion diverticulum of mucosa of posterior pharyngeal wall between cricopharyngeus and the rest of inferior constrictor
Clinical features of a pharyngeal diverticulum/pouch?
Dysphagia, regurgitation and gurgling sensation on swallowing
Treatment of pharyngeal diverticulum/pouch?
surgical excision
What is a laryngocele?
Sac containing air and pus on the medial surface of thyroid cartilage
Clinical presentation of laryngocele?
Hoarseness & swelling in the neck
Can be filled by asking patient to perform Valsalva maneuver
Dangerous as it may compress the airway
Treatment of a laryngocele?
endoscopic division of cricopharyngeal muscle using a Dolhmans pharyngoscope and a stapling gun or surgical excision
What is unilateral cervical lymphadenopathy?
localized swollen lymph nodes on one side of the neck
- is usually associated with bacterial infections
Etiology of unilateral cervical lymphadenopathy?
- Acute
- S. aureus, Group A Streptococcus (e.g., Streptococcus pyogenes), oral anaerobes, Group B Streptococcus (GBS). - Subacute/chronic
- Nontuberculous mycobacteria (e.g., M. avium-intracellulare and M. scrofulaceum), Mycobacterium tuberculosis. - Kawasaki disease
- Malignancy
- leukemia, lymphoma, metastasis of oral mucosa cancers - Connective tissue disorders
e.g., juvenile rheumatoid arthritis, systemic lupus erythematosus
What are the clinical features of unilateral cervical lymphadenopathy?
- Usually child appears healthy; possibly history of preceding upper respiratory tract infection or dental conditions
- fever, malaise, tachycardia
- Lymph node involvement
- Most common: submandibular or deep cervical nodes
> large, tender, warm, possibly erythematous skin over the node
> may become fluctuant and form an abscess over time or become indurated. - Chronic cases
- insidious enlargement; nontender, immobile, matted nodes; may form to sinus tracts
Investigations done in unilateral cervical lymphadenopathy?
CBC, ESR, CRP, Tuberculin test in chronic cases, Blood culture, Throat swab and oral swab, Gram stain and culture after fine needle aspiration, excisional biopsy
Imaging: ultrasound exam or CT scanning
Imaging done in unilateral cervical lymphadenopathy?
ultrasound exam or CT scanning
Treatment for unilateral cervical lymphadenopathy?
- Antibiotics 10-14 days
- Conservative management if no fever and non-tender lymphadenopathy.
- Supportive therapy: antipyretics, analgesics, warm compresses
- Surgical measures: incision and drainage of large abscesses
What is a peritonsillar abscess?
Most common deep neck infection
Epidemiology of peritonsillar abscess?
Common in adolescents and young adults
Etiology of peritonsillar abscesses?
- Streptococcus pyogenes (most common)
- Streptococcus anginosus, viridans streptococci
- Staphylococcus aureus
- Haemophilus species
Clinical features of peritonsillar absecess?
- Features of tonsillitis: fever, malaise, severe sore throat, dysphagia, and odynophagia, drooling, or halitosis.
- Uvula shifted to the contralateral side, with inferior and medial displacement of tonsil
- Unilateral fluctuant, swollen, erythematous tonsil with exudates (ipsilateral bulging of the palatine arch)
- Ipsilateral cervical lymphadenopathy (and neck swelling)
Treatment of peritonsillar absesses?
- Airway management is always the first step!
- IV antibiotics
- Incision and drainage or needle aspiration
- Tonsillectomy
What is a pharyngeal absess?
Epidemiology of pharyngeal absess?
Most common in children < 5 years of age
Etiology of pharyngeal absess?
- Streptococci (viridans streptococci, S. pneumoniae)
- staphylococci (including MRSA)
- Haemophilus influenzae, oral anaerobes
Clinical features of pharyngeal absesses?
- Features of peritonsillar abscess, especially trismus
- Respiratory distress: dyspnea, stridor
Limited cervical neck extension
Describe what a pharyngeal abscess looks like?
- Posterior space abscess: medial displacement of the lateral pharyngeal wall and tonsil
- Anterior space abscess: indurated swelling below the angle of the mandible down to the hyoid bone
Treatment of pharyngeal abscess?
- Airway Management
- IV broad spectrum antibiotics
- Surgical drainage
What is a retropharyngeal absess?
Generally, the most dangerous deep neck infection
Epidemiology of a retropharyngeal absess?
Most common in children < 5 years of age
Causes of retropharyngeal abscess?
can be direct or indirect
1. Contiguous or lymphatic spread from oral (most common) or upper respiratory tract infections
2. Local penetrating pharyngeal trauma (e.g., from small bones such as of fish or chicken, or medical instruments)
3. Spread from other deep neck infections (nasopharynx, sinuses, adenoids)
Clinical features of a retropharyngeal absess?
Features of tonsillitis and trismus (minimal), Neck asymmetry with unilateral swelling of the posterior pharyngeal wall, inability to extend neck, Torticollis, Anterior cervical lymphadenopathy and Respiratory distress
Treatment for a retropharnygeal abscess?
airway management, surgical drainage
Name salivary gland disorders?
- tumours
- stones
- infections - mostly bacterial
Tumours of the salivary glands?
- Pleomorphic adenoma
- Adenolymphoma
- Malignant primary tumours( adenocystic Ca, acinic cell Ca, SCC)
- Malignant Secondary tumours ( metastases)
Name congenital thyroid disorders?
- Thyroglossal cyst
- Thyroglossal fistula
- Ectopic thyroid
What is acute thyroiditis?
Definition
Usually, bacterial infection caused by persistent pyriform sinus fistula or trauma.
Clinical features
Intense pain over thyroid with skin erythema, radiating to jaw or ears.
Treatment
iv broad spectrum antibiotics, surgical drainage if abscess present
What is subacute thyroiditis?
Commonest cause of painful thyroid
Assoc with viral infection (coksackie, mumps, measles, infectious mono)
Firm, enlarged thyroid
Rx – NSAIDs, rx of hyper/hypothyroidism
What is chronic thyroiditis?
Commonest cause Hashimoto’s thyroiditis
Autoimmune
Small, firm gland / enlarged thyroid goitre
Rx – supportive and rx of hypothyroidism. Surgery if goitre compressive
What is Simple non-toxic colloid goiter?
Very common
Benign
Diffuse or multinodular hyperplasia
What is endemic goiter?
Rare
Diffuse hyperplasia
Dietary iodine deficiency
What is drug induced goiter?
Uncommon
Diffuse thyroid hyperplasia
Antithyroid drugs e.g. carbimazole, lithium, aminoglutethimide
What is physiological goiter?
Common
Diffuse hyperplasia
Pregnancy, puberty
What are surgery indications for goitre?
Compressive symptoms
Substernal growth
Presence of nodule(s) >4cm or toxic MNG
Disfigurement, cosmetic reasons
Family hx of thyroid ca or exposure to therapeutic ratiation
What is papillary thyroid cancer?
80% of thyroid ca
Originate from follicular epithelium
Well differentiated ca, slow growing, not aggressive
Classic finding – psammoma bodies, orphan annie nuclei
Rx – thyroid lobectomy or commonly total thyroidectomy
What is follicular thyroid cancer?
15% of all thyroid ca
Well differentiated
Workup and mgt similar to PTC
What is medullary thyroid cancer?
15% of all thyroid ca
Well differentiated
Workup and mgt similar to PTC
Examination of a neck mass?
Size
Site
Shape
Surface characteristics
Fixation ( superficial & deep)
Consistency
Fluctuance
Pulsatility
Temperature
Transilluminability
Bruit
Local lymphadenopathy
