Neck Masses Flashcards
What is the only muscle of the larynx that is not supplied by the recurrent laryngeal nerve? What is it supplied by?
- Cricothyroid muscle
- External branch of the superior laryngeal nerve (branch of CN X)
What are the boundaries of the occipital triangle?
- Trap
- SCM
- Omohyoid
What are the boundaries of the submental triangle?
- Anterior digastric
- Mandible
What are the boundaries of the submandibular triangle?
- Ant digastric
- Post digastric
- Mandible
What are the boundaries of the carotid triangle?
- Omohyoid
- SCM
- Stylohyoid
What are the boundaries of the muscular triangle?
- SCM
- Omohyoid
- Midline
What are the boundaries of the subclavian triangle?
- Clavicle
- SCM
- Trap
Who in particular can feel their carotid bulb?
People who lose weight
Where are lymphatic areas II, III, and IV in the neck?
Along the SCM from superior to inferior, and transecting it into thirds
Where is the lymphatic area I in the neck?
Submental /submandibular triangle
Where is the lymphatic area VI in the neck?
Muscular triangle
Where is the lymphatic area V in the neck?
Posterior triangle
What percent of neck masses in kids 0-15 years are benign?
90%
What is the “rule of 80s” for adults greater than 40 yo in terms of neck masses?
80% of neck masses are neoplasms, and 80% of those are malignant
Upper jugular chain masses are mets from where? (1)
Nasopharynx
Mets in the posterior triangle are from where? (4)
- Nasopharynx
- Ear
- Temporal bone
- Skull base
Mets in the lower jugular chain are from where? (2)
Upper esophagus or thyroid
Mets in the submandibular triangle are from where? (3)
- Anterior 2/3 of tongue
- Floor of
- Cheek
Mets in the Submental area are from where?
Lip
Mets in the mid jugular chain area are from where? (3)
Any portion of the oral cavity, pharynx, or larynx
What are the risk factors for developing head and neck cancers?
- Chronic sun exposure
- Poor dentition
- Smoking/EtOH use
What is the classic presentation of a cancerous lesion in the oral or nasopharynx? (5)
- Nonhealing ulcer
- Persistent sore throat
- Dysphagia
- Change in voice
- Otalgia with exam
Where in particular should you assess when suspecting a neck neoplasm?
- Tonsillar fossa
- Pharynx and larynx with a fundoscope
What are ways that can aid you in assessing for neoplasms in the head and neck?
Rotation in both flexion and extension
Palpation of the neck with what two maneuvers may aid you in identifying pathology in the larynx and thyroid?
Swallowing or Valsalva
What should always be done with an inflammatory neck mass, prior to further investigation?
2 week course of abx
What are the ways to diagnose neoplasms of the neck? What is the standard?
- FNA bx
- CT
- MRI
- US
True or false: if a neck mass is NOT an obvious abscess should be biopsied
True
Persistence of a neck mass after how many weeks of abx should be biopsied?
2 weeks
Any mass measuring how many cm should be biopsied?
3 cm
True or false: any neck mass that is accompanied by s/sx of lymphoma should not be biopsied, since it is almost always lymphoma
False
What are the four major indications for FNA of a neck mass
- Not obvious abscess
- Persistence after 2 weeks of abx
- Progressive growth or more than 3 cm
- s/sx of lymphoma
True or false: there is a risk of seeding cancer with a FNA
False
How many samples of the mass should be taken with a FNA?
4
What are the benefits of a CT scan when evaluating a neck mass?
Can identify cystic or solid, and can see if it is a met from a distant site/ see the primary site
When should a CT with contrast not be obtained when evaluating a neck mass?
If suspected thyroid lesion
When is an MRI preferable to CT in evaluating head and neck tumors?
Skull based or vascular invasion
What is the role of radionuclide scanning in evaluating head/neck masses?
- salivary and thyroid masses
- Functional information
Which are classically cancerous: hot or cold thyroid nodules?
Cold
What is the most common type of cancer of the head and neck?
SCC
Ipsilateral otalgia with a normal ear examination should be suspicious for a tumor where?
Tonsils, tongue base, supraglottic area
Asymptomatic, unilateral serous otitis should be suspicious for what?
Nasopharyngeal tumor obstructing the eustachian tube
What are the two indications for a panendoscopy?
- FNAB + with no primary mass located
- FNAB equivocal or negative in a high risk pt
What is the incidence of synchronous primary tumors in the nasopharynx?
10-20%
When is an open excisional bx indicated for head and neck?
Only if complete workup is negative
What are the two work ups that should be done on a neck mass if it does not respond to abx?
CA vs TB
What is the leading cause of anterior neck masses?
thyroid CA
What is the most common neoplastic condition of the head and neck in children? Which gender is usually affected? Are these usually benign or malignant?
Thyroid masses
Males
Malignant
What gender is more affected with thyroid masses in the adult population? Are these usually benign or malignant?
Females
Benign
True or false: lymph node involvement with papillary thyroid carcinomas is relatively common
True–40%
What should be done if there is an inadequate sample taken with a FNA of the thyroid?
Repeat in 1 month
What percent of kids with lymphoma have a neck mass?
80%
What are the neck s/sx of lymphomas?
- Lateral neck mass
- Fever
- HSM
- Diffuse adenopathy
What is the first line test for evaluating a neck mass that is suspicious for a lymphoma?
FNA
What should be done if a FNA comes back positive for lymphoma?
Open bx and full CT scan of the head/neck, chest, and abdomen
What percent of parotid tumors are benign?
80+%
What are the associated symptoms of salivary gland tumors?
- rapid growth
- Skin fixation
- CN palsies
What is the accuracy of FNA with salivary gland tumors?
More than 90% sensitive and 80% specific
What is the treatment for parotid gland tumor?
Total parotidectomy, with possible facial nerve sacrifice
What are the characteristics of carotid body tumors?
- Pulsatile mass that is compressible
- Mobility medially and laterally, but NOT superior/inferiorly
How do you diagnose carotid body tumors?
Clinically or confirmed with angio CT
What is the treatment for a carotid body tumor?
XRT or close observation in the elderly
How common are carotid body tumors in children?
Extremely rare
Where is the carotid body?
At the bifurcation of the carotids
What are the characteristics of lipomas?
Soft, asymptomatic masses
What is the age range that usually gets lipomas?
35+
how do you diagnose lipomas?
Clinically
What is the role of FNA with lipomas?
Not very beneficial–just get ghost image
What are the cells that give rise to neurogenic tumors?
neural crest cells
What are the neurogenic tumors in the head/neck region?
- Schwannoma
- Neurofibroma
- Malignant peripheral nerve sheath tumor
What inherited disease predisposes pts to neurogenic tumors?
NF
Are schwannomas usually more sporadic or caused by diseases like NF2?
Sporadic
What is the age range that more commonly gets schwannomas?
20-50 years
Where are schwannomas usually located?
Mid-neck in poststyloid compartment
What are the usual s/sx of schwannomas? (3)
- Medial tonsillar displacement
- Hoarseness (vagal nerve compression)
- Horner’s syndrome
What nerve, if compressed, leads to hoarseness?
Recurrent laryngeal branch of CN X
What is the most common congenital/developmental mass?
Epidermal and sebaceous cysts
How do you diagnose epidermal / sebaceous cysts?
Clinically, with excisional bx as confirmation
What are the PE findings of epidermal / sebaceous cysts?
- Elevation and movement of overlying skin
- Skin dimple or pore
Which of the branchial clefts usually develop into branchial cleft cysts? Which rarely do?
2nd is the most common, and 1st less but still
3 and 4 rarely reported
Where are branchial cleft cysts of the 2nd branchial cleft located?
tract medial to CN XII between internal, and external carotid
Which branchial cleft is associated with CN VII?
2nd
When do branchial clefts cysts usually become apparent? Why?
After a URI, since infection will stimulate mucus production, and the clefts are enclosed mucous membranes
What are the PE findings of branchial cleft cysts?
- Smooth, fluctuant mass underlying the SCM
- TTP and erythema if infected
What is the treatment for branchial cleft cysts?
Surgical excision, including tract
Which branchial cleft cyst may need a parotidectomy to treat?
First
What is the most common type of congenital neck mass?
Thyroglossla duct cysts
What percent of thyroglossal duct cysts present before age 20?
50%
Where are thyroglossal duct cysts usually located? What are the common signs of this, then?
- Just inferior to the hyoid bone
- Elevates on swallowing/protrusion of the tongue
What is the treatment for thyroglossal duct cysts?
Surgical removal
What are the two major vascular tumors of the head and neck? When do they usually present?
- Lymphangiomas and hemangiomas
- 1st year of life
What is the prognosis for hemangiomas and lymphangiomas?
- Hemangiomas = Resolve spontaneously
- Lymphangiomas = remain unchanged
What is the treatment for lymphangiomas and hemangiomas?
- Lymphangiomas = surgical excision
- Hemangiomas = Surgical excision if rapidly growing and involving vital structures, or associated with thrombocytopenia
How common is lymphadenitis?
very common, especially in the first decade
What are the signs of lymphadenitis?
Tender noes with signs of systemic infection
What is the treatment for lymphadenitis?
abx
What are the indications for FNA for lymphadenitis?
- Actively infectious
- Progressively enlarging
- Solitary and asymmetric
- Supraclavicular mass
- Persistent nodal mass
What is granulomatous lymphadenitis?
a chronic specific granulomatous inflammation of the lymph node with caseation necrosis, caused by infection with Mycobacterium tuberculosis or other bacteria
What are the PE findings of granulomatous lymphadenitis?
Firm, fixed node with injection of the skin
Actinomycosis is usually found in people with what condition?
Poor dental hygeine
