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m4 ENT > Neck masses > Flashcards

Neck masses Flashcards

1
Q

Borders about anterior triangle

A

Superior: Lower border mandible
Anterior: Midline
Posterior: Anterior border of SCM

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2
Q

Borders about posterior triangle

A

Anterior: Posterior border of SCM
Posterior: Anterior border of trapezius
Inferior: Clavicle

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3
Q

Main contents of anterior triangle

A

Nerves
· Glossopharyngeal nerve (CN IX)
· Vagus nerve (CN X)
· Spinal accessory nerve (CN XI)
· Hypoglossal nerve (CN XII)

Arteries
· Common carotid artery (including
internal and external carotid
arteries)
· Facial artery
· Lingual artery
· Superior and inferior thyroid arteries

Veins
· Internal jugular vein
· Anterior jugular vein
· Facial vein

Muscles
· Suprahyoid muscles
· Infrahyoid muscles

Organs
· Submandibular gland
· Parotid gland (caudal part)
· Thyroid and parathyroid glands
· Larynx and trachea
· Esophagus

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4
Q

Main contents of posterior triangle

A

Nerves
· 3 trunks of brachial plexus
· Spinal accessory nerve (CN XI)
· Cutaneous branches of cervical
plexus

Arteries
· 3rd part of subclavian artery
· Suprascapular artery
· Occipital artery
· Transverse cervical artery

Veins
· Subclavian vein
· External jugular vein

Muscles
· Inferior belly of omohyoid
muscle

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5
Q

Commonest neck mass

A

Enlarged lymph nodes

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6
Q

Differential diagnosis of neck lumps: Midline of neck

A

Lymph node
Thyroglossal cyst
Dermoid cyst
Plunging ranula
Thyroid nodule

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7
Q

Differential diagnosis of neck lumps: Anterior triangle

A

Lymph node
Thyroid nodules
Branchial cyst
Lymphadenopathy
Submandibular gland disease
Plunging ranula
Benign skin lesions
Carotid body tumour
Carotid aneurysm
Nerve sheath neoplasm

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8
Q

Differential diagnosis of neck lumps: Posterior triangle

A

Lymph node
Lymphadenopathy
Benign skin lesions
Brachial plexus schwannoma/neuroma
Malignant neoplasm
Cystic hygroma
Pharyngeal pouch (Zenker’s diverticulum)
Cervical rib

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9
Q

What is Virchow’s node?

A

Palpable left supraclavicular lymph node
= Trosier’s sign
Due to abdominal malignancy, it drains into thoracic duct which drains into left supraclavicular lymph node

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10
Q

Embryology of thyroglossal cyst

A
  • Congenital
  • Cystic expansion of remnant thyroglossal duct tract which failed to obliterate after embryonic descent of thyroid from foramen cecum (Junction of anterior 2/3 and posterior 1/3 of tongue) at base of tongue to neck overlying trachea and thyroid cartilage
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11
Q

Feature of a thyroglossal cyst

A

Midline anterior neck mass that enlarges with URTI and elevates with swallowing and tongue protrusion

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12
Q

Pre-op investigations for thyroglossal cyst

A

CT/ U/S neck to look for thyroid gland to ensure that there’s native thyroid tissue elsewhere as patient has to be on lifelong thyroxine if only source of thyroid tissue is removed (Also to look at size, extent and location for surgical planning)

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13
Q

Management of thyroglossal cyst

A

Sistrunk procedure
- Indications:
1. Increase in size
2. Infected and becomes abscess/ fistula 3. Compressive symptoms
4. Malignancy

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14
Q

What is a plunging ranula?

A

Submucous retention pseudocyst arising from an obstruction in the sublingual glands in the floor of mouth, due to mucous extravasation, “plunging” through the mylohyoid muscle

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15
Q

Feature of ranula

A

Blue, fluctuant, painless, slow growing
Found at floor of mouth

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16
Q

Causes of plunging ranula

A

Congenital or acquired after oral trauma to sublingual gland leading to mucus extravasation and obstruction to sublingual gland drainage

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17
Q

Types of ranula

A
  • Simple ranula: Confined to floor of mouth lateral to midline
  • Plunging ranula: Extends through mylohyoid musculature of floor of mouth, presenting as superior neck mass
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18
Q

Management of plunging ranula

A
  • Complete resection with sublingual gland (Difficult due to close association with lingual nerve and submandibular duct)
  • Sclerotherapy with OK-432
19
Q

Dermoid cyst

A

Growth of normal tissue enclosed in a pocket of cells called a sac
- Complete surgical excision of cyst

20
Q

Causes of submandibular masses

A
  1. Arise from submandibular gland or enlargement of submandibular nodes
  2. Infection or mets from primary tumour of oral cavity –> Reactive submandibular lymphadenopathy
  3. Calculi in submandibular duct –> Sialadenitis –> Painful intermittent fluctuating enlargement of submandibular gland triggered by meals
21
Q

Branchial cyst

A
  • Young adults
  • Second branchial cyst is most common
  • Lined by squamous epithelium
  • Inferior to angle of mandible and anterior to SCM
  • Slowly enlarging and painless
    ↑ in size after URTI
  • Firm and fluctuant but NOT transilluminable due to desquamated cell contents
22
Q

Complication of branchial cyst

A

Cyst recurrence
Chronic discharging sinus

23
Q

Management of branchial cyst

A

Surgical excision

24
Q

What is a carotid body tumour/carotid aneurysm?

A

Paraganglioma of the carotid body at the
bifurcation of the common carotid artery

25
Q

Clinical feature of carotid body tumour

A
  • Slowly enlarging and painless
  • Pulsatile mass but not expansile (transmitted pulsation from carotids) at bifurcation of common carotid artery into ICA and ECA
  • Fontaine sign positive = Lump is and can move mobile side to side but not up and down as it’s located within carotid sheath
26
Q

Risk of malignancy of carotid body tumour

A

Usually benign, but locally invasive
10% risk of malignancy with mets to lymph nodes

27
Q

What investigation is contraindicated in a carotid body tumour?

A

DON’T DO FNAC!!!

28
Q

Investigation to perform for carotid body tumour

A

Assess tumour activity and TRO phaeochromocytoma:
- 24 hour urine catecholamine

Localisation:
- US duplex
- MRI with angiography

29
Q

Gold standard investigation for carotid body tumour

A

Angiography showing hypervascular mass displacing bifurcation and splaying of ICA and ECA (Lyre’s sign)

30
Q

Management for carotid body tumour

A
  • Surgical excision with pre-operative embolization
  • Radiotherapy for those unfit for surgery and too large tumours
31
Q

What is pharyngeal pouch / zenker’s diverticulum?

A

Herniation of pharyngeal mucosa and submucosa through Killian’s Dehiscence (△)
- Weak area between 2 parts of inferior pharyngeal constrictor (thyropharyngeus and cricopharyngeus) posteriorly

32
Q

Clinical features of pharyngeal pouch / zenker’s diverticulum

A
  • Squelching sound on deep palpation from free fluid in pouch
  • Hoarseness
  • Halitosis (stagnant food digested by microorganisms)
  • Regurgitation of undigested food
  • Dysphagia
  • LOW
33
Q

Complication of pharyngeal pouch / zenker’s diverticulum

A

Aspiration pneumonia
Diverticular neoplasm

34
Q

Dx for pharyngeal pouch / zenker’s diverticulum

A

Barium swallow

35
Q

Management of pharyngeal pouch / zenker’s diverticulum

A
  • Leave alone if small and asymptomatic
  • Diverticulectomy or diverticulopexy (Inversion of lumen of pouch in caudal direction so food and secretions can’t enter pouch, but risk of malignancy still remains as diverticulum still present)
36
Q

Cervical rib

A
  • Congenital, extra rib arising from C7 vertebra located above 1st rib, unilateral or bilateral
  • Can compress on subclavian artery and lower trunk of brachial plexus (C8, T1) –> Thoracic outlet syndrome:
    1. Arterial: Pallor, coldness
    2. Venous: Edema, cyanosis
    3. Neurological: Pain, paraesthesia, wasting of small muscles of hand
    4. Adson’s test: Radial pulse diminished when patient actively extends neck and rotates it towards side of symptoms

Dx:
CXR

37
Q

Cystic hygroma

A
  • Congenital cystic lymphatic malformation consists of thin-walled, single or multiple interconnecting or separate cysts containing lymphatic fluid
  • Soft, fluctuant and compressible into retropharyngeal space
  • Transilluminable
  • Suggests chromosomal (Down, Turner, Noonan syndrome) or other structural (cardiac, skeletal) abnormalities
  • Compressive problems:
    Respiratory
    Swallowing
38
Q

Levels of LNs in the head and neck region

A

Level I: Between midline and anterior aspect of SCM (Submental)
Level II: Between mastoid and hyoid
Level III: Between hyoid and cricoid
Level IV: Between cricoid and sternum
Level V: Behind posterior aspect of SCM
Level VI: Trachea-esophageal group

39
Q

Causes of cervical lymphadenopathy

A
  1. Infection
  2. Inflammatory
  3. Neoplastic
40
Q

Infective causes of cervical lymphadenopathy

A

Viral:
- EBV
Infective mononucleosis = Fever + Pharyngitis + Tonsillitis
Maculopapular rash from amoxicillin
Hepatitis
Tender/ Painful LNs
- HIV
Kaposi sarcoma’s
Mets to cervical LNs

Bacteria:
- Strep
- Staph
- Klebsiella (DM patients)
- TB (TB cervical lymphadenitis)
2nd commonest Dx of excised LNs
Ix: CXR, swab discharging sinus for AFB, TB PCR, culture
Mx: Notify MOH, isolate patient, check contact Hx, anti-TB medications (Rifampicin and isoniazid for 4 months, R, I, pyrazinamide and ethambutol for another 2 months)

Fungal

Parasitic: Toxoplasma

41
Q

Inflammatory causes of cervical lymphadenopathy

A

Kikuchi lymphadenitis
- Young females
- Recurrent episodic painful ‘flaring up’ of nodes which resolve spontaneously (Waxing and waning pattern)
- Last for weeks to months
- LNs are not very large but palpable and sometimes visible
- ± Fever
- Dx: Excision biopsy (TRO Hodgkin’s lymphoma esp in young patients)
Histo: Necrotizing lymphadenitis
- DDx: Lymphoma, SLE
- Nil specific Tx

Kimura
Kawasaki disease
SLE
Sarcoidosis
RA

42
Q

Neoplastic causes of cervical lymphadenopathy

A
  1. Lymphoma (Arise from LN itself)
  2. Mets
    - Primary site: H&N (90%)
    -> drains through lymphatics to cervical LNs
    -> NPC, oral cavity, oropharynx, tonsils, larynx, hypopharynx/ laryngopharynx, thyroid, skin
  • Infraclavicular areas (Virchow’s node)
    -> Lungs, breast, GUT, GIT

*Must ask about epistaxis, blood in saliva, unilateral blocked ear, throat pain, odynophagia, change in voice

43
Q

What type of cancer is most likely to develop in a patient with thyroglossal duct cyst?

A

Papillary thyroid ca

m4 ENT (25 decks)

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