Neck Masses Flashcards
What are the neck boundries
- mandible
- zygomatic process of the temporal bone
- External auditory canal
- mastoid
- superior nuchal line
- external occipital protuberance
- manubrium sterni
- clavicle
- acromio-clavicoular joint
- spinous process of 7th cervical vertebra
Name the cervical fasciae
- Superficial cervical fascia - Contains the platysma muscle.
- Deep cervical fascia - Contains the nerves (cervical plexus), muscles and vessels
- Middle cervical fascia
- Linea alba (midline)
Describe the neck triangles and what is found in-between them
Anterior triangle: SCM, midline, inferior margin of the mandible
Posterior triangle: SCM, clavicle, trapezius muscle.
In the line between the anterior and posterior triangles, there is a carotid sheath which contains the common carotid artery, internal jugular vein, and vagus nerve.
Fully detail how the lymph node levels of the neck are divided
Level I, submental (IA) and submandibular (IB);
level II, upper internal jugular nodes;
level III, middle jugular nodes;
level IV, low jugular nodes;
level V, posterior triangle nodes;
level VI, upper visceral nodes; (anterior compartment)
level VII, superior mediastinal nodes.
Comment on the main neck pathologies and how they are divided (by proportion)
90% of the cases there is a pathology that affects the lymph nodes.
10% of the cases it affects: connective tissue, vessels, nerve tissue and vestigial remnants.
The lymph node pathology can be: Inflammation • Infections • TBC • Toxoplasmosis • Drugs adverse effects • HIV
Neoplastic metastasis
• Solid tumor
• Lymphoma
Other • Abscess • Salivary glands disorders • Thyroid diseases • Branchial cyst, congenital teratoma) • Nervous disorders (neurinoma, schwannoma) • Vascular malformations (hemangioma, lymphangioma) • Laryngocele
Detail the diagnostic work-up of neck masses (incl. physical examination and lab diagnosis)
Clinical History
- Epidemiological aspects: age, sex, race, occupation, tropical journey, smoke, alcohol, drugs
- Local symptoms: dysphagia, odinophagia, otalgia, cough, dyspnea, dysphonia
- Systemic symptoms: nocturnal sweating, weight loss, asthenia, fever
PHYSICAL EXAMINATION
Mass:
• Single mass (and mobile -> probably benign)
• Multiple masses (nodal-chain)
• Nodal package (fixed on the deep part of the neck -> probably malignant)
Skin Evolution • Color • Motility • Thickness • Associated skin lesions (ulcer, fistulae)
Consistency
• Soft/tender (cysts, laryngocele)
• Rubbery (lymphoma)
• firm (metastasis)
Pain
• Type
• Site and irradiation
• Time and modality of onset
Motility
• Movable/fixed to underlying structures
General Physical examination
• Abdominal and mediastinal lymphadenopathies etc.
• Skin and mucosal characteristics
ENT examination should be performed if any of the following are suspected:
• Primary head and neck neoplasm
• Infections
• Systemic diseases
LABORATORY TESTS o Hemochrome with WBC Counts o Inflammatory markers (VES, CRP) o Pharyngeal swab o Infectious diseases specific tests: TAS, Heterophil test, toxotest, anti-HIV Ab e anti-CMV Ab, Mantoux)
Detail the 1st and 2nd level instrumental exams (for neck mass)
1st Level exams
- Ultrasound
- Pharyngo-laryngeal endoscopy
- Chest x-ray
2nd level exams
(performed when 1st level is inconclusive)
- CT and/or MRI
- FNAC if you suspect a malignant mass
- Lymphadenectomy if you suspect lymphoma
Detail the potential causes of masses with liquid content and masses with solid content
Masses with LIQUID content
- Inflammatory lymph nodes and adcesses
- Brachial cysts
- Cystic Metastasis (thyroid papillary carcinoma)
Note: cystic masses of the neck aren’t always benign
Masses with SOLID content
Upper site:
Lymphadenitis (example: acute tonsillitis)
Pharyngo-laryngeal cancer metastasis
Non-Hodgkin lymphoma involving Waldeyer ring
Salivary glands neoplasm, vascular tissue neoplasm, nervous system neoplasm.
Lower site:
Thyroid pathology (median swelling, fixed to deep structures, that moves on swallowing)
Pulmonary tuberculosis
Hodgkin lymphoma (normally affecting the inferior part of the node)
Pulmonary sarcoidosis
Lungs (or sub-diaphragmatic structures) cancer metastasis (especially on the left)
List causes of BILATERAL masses with solid content
Infectious Mononucleosis
Toxoplasmosis
HIV
Systemic diseases (exanthematous disease, autoimmune diseases, secondary syphilis, drug-induced generalized lymphadenopathy)
Fully describe Infectious Mononucleosis
Acute disease characterized by usually occurring in 1°and 2°decade of life. Suspect mono in young pts with lymphadenopathy and high grade fever resistant to normal treatment, and ENT signs (pharyngitis like)
Presentation o Generalized lymphadenopathy (It can be the only sign) - present in 90% of cases o Influenza-like illness o High grade Fever o Angina o Hepatosplenomegaly o Eyelid swelling
Characteristic Adenopathy o Site: more commonly occipital & spinal (especially posterior cervical) o Multiple and bilateral o Painful o Size: 1-3 cm
Diagnosis:
o Heterophile test
o EBV Abs test
o Paul-Bunnell test
Therapy
o Symptomatic treatment
o Antibiotics if angina present (cephalosporin III + metronidazole)
Discuss Lymphoma in head and neck region and its diagnostic work-up
Lymphoma is a systemic disease with high involvement of head and neck region:
o 70-80% - Hodgkin lymphoma
o 30-45% - Non-Hodgkin lymphoma
Age of onset peaks:
o 3 - 4 decade - Hodgkin lymphoma
o 5 - 6 decade - Non-Hodgkin lymphoma
Characteristic Adenopathy
o Single mass/multiple mass/ nodal package
o Consistency:
• Rubbery (not firm)
• Not fixed
• Painful
• Variable size
o Possible involvement of Waldeyer’s ring
o Less frequent location: salivary glands, lacrimal glands, orbit, thyroid, larynx
Diagnosis:
o FNAC -> cytological diagnosis
o Lympha-dencetomy -> histological diagnosis
o The final diagnosis is based on a lymph node biopsy (The FNA is not enough)
Describe what Abscesses are, their risk factors, and diagnostic work up
Definition - enclosed collection of pus in a specific tissue of the body, often accompanied by swelling and inflammation, frequently caused by pyogenes bacteria.
• Abscess can progress to SIRS. IMPORTANT TO REACH DIAGNOSIS QUICKLY
• Mortality 7-18%
Risk factors: o Diabetes o Immunosuppressive therapies o Onco-hematological cancer (these 3 are the most important) o Radiotherapy o Prematurity o Malformative diseases o Trauma o Intensive care hospitalization
If the neck abscess migrates to the mediastinum it will require drainage.
Diagnostic work-up
- Blood chemistry • Increase in WBC (neutrophilia) • Increase of inflammatory markers (ESR, CRP, fibrinogen, procalcitonin) - Bacteria Culture - Anti-biogram
Describe the SIRS criteria
Two or more of the following:
- Temperature > 38 or < 36
- Heart rate > 90bpm
- Respiratory rate > 20 or PCO2 < 32mmHg
- WBC > 12.000 or < 4000
Elaborate on Retropharyngeal abscesses
The retropharyngeal space is posterior to the pharynx and esophagus, and extends from the base of the skull to a variable level between the T1 and T6 vertebral bodies. It is a midline space that consists largely of fatty areolar tissue and contains lymph nodes that drain the pharynx, nose and middle ear. (this is just background info)
Etiopathology:
o Cervical infection that involves the lymphatic drainage pathway in the pharynx, paranasal sinuses, salivary glands, middle ear, prevertebral space.
o Most commonly caused by peri-tonsillar abscess and pyogenic lymphadenitis
o Other causes: foreign body ingestion (» children)
o Cervical osteomyelitis
o Iatrogenic (after head and neck surgery)
Symptoms They are not specific and require imaging o Nucal rigidity - most important (inability to flex the neck forward due to rigidity) o Fever o Sore throat o Dysphagia o Dyspnea o Painful Cervical swallowing
Early Diagnosis o Endoscopic evaluation o Ultrasonography o CT o MRI
Treatment - has to be aggressive
o Antibiotic treatment
o Surgery for incision and drainage of abscess
Describe branchial cleft cysts
Branchial cleft cysts are remnants of embryonic development and result from a failure of obliteration of one of the branchial clefts
Age peak: II –III decade
Site: mainly in upper jugular level
Characteristics: - Single mass - Size: 2 -7 cm - Consistency: • Soft/rubbery • Liquid content
Diagnosis:
o Ultrasonography
o FNAC
• Specific features of cysts derived from each branchia cleft:
1st Branchial Arch
• Superficial cyst under the superficial cervical fascia, anterior to SCM muscle
• Possible attachment to parotid gland and facial nerve, possible extension to the external auditory canal.
2nd Branchial Arch
• 95% of the branchial anomalies
• Superficial cyst under the superficial cervical fascia, anterior the CCA and IJV
• In relation to IJV
• Frequent localization to mandibular angle
• Liquid content
• Asymptomatic
3rd and 4th Branchial Arch
• Extension to the pharynx
• Can have an opening into the skin near the clavicle.
• Rare
