Neck Masses Flashcards
What is Rosai-Dorfman Disease?
AKA Sinus histiocytosis with massive lymphadenopathy (SHML)
- rare disorder of unknown etiology that is characterized by abundant histiocytes in the lymph nodes throughout the body
- involves the over-production of a type of white blood cell called non Langerhans sinus histiocyte.
- These cells then accumulate, most often in the lymph nodes, but may occur in other areas of the body and can lead to organ damage. The reason that these cells over-produce is not known, although many possibilities have been considered, including viral, bacterial, infection, environmental, and genetic causes.
- emperipolesis - cells within cells
What is Fibromatosis colli?
aka Sternomastoid tumor of infancy
- Benign proliferation of fibrous tissue infiltrating the lower third of the sternocleidomastoid or shoulder region, and is the most common cause of neonatal torticollis
What is Kikuchi disease?
Kikuchi-Fujimoto disease (KFD)
- Rare, self-limiting disorder that typically affects the cervical lymph nodes.
- The cause of this disease is not known although infectious and autoimmune etiologies have been proposed
- Recognition of this condition is crucial, especially because it can easily be mistaken for tuberculosis, lymphoma, or even adenocarcinoma.
- Kikuchi’s disease is a very rare disease and mainly seen in Japan
- Course of the disease is generally benign and self-limiting
- Treatment is symptom based
List the Anterior Cervical Triangles
Boundaries: midline of the neck, posterior border of the sternocleidomastoid muscle, and inferior border of the mandible
- Submandibular Triangle: bordered by the inferior border of the mandible, and by anterior and posterior digastric muscles
- Submental Triangle: bordered by the anterior belly of the digastric, hyoid bone, and midline of the neck
- Carotid Triangle (Superior Carotid Triangle): bordered by the omohyoid muscle, posterior belly of the digastric muscle, and the posterior border of the sternocleidomastoid muscle
- Muscular Triangle (Inferior Carotid Triangle): bordered by the omohyoid muscle, midline of the neck, posterior border of the sternocleidomastoid muscle
List the Posterior Cervical Triangles
Boundaries: clavicle, posterior border of the sternocleidomastoid muscle, anterior border of the trapezius muscle
- Occipital Triangle: bordered by the posterior border of the sternocleidomastoid muscle, anterior border of the trapezius muscle, and the omohyoid muscle
- Subclavian Triangle: bordered by the posterior border of the sternocleidomastoid muscle, the clavicle, and the omohyoid muscle
- Contents of the Posterior Triangle: scalene, posterior cervical, and supraclavicular nodes; pleural apices; phrenic nerve, brachial plexus (trunks); subclavian artery and vein; anterior scalenes; thyrocervical trunk branches (dorsal scapular, transverse cervical, supraclavicular, and inferior thyroid arteries)
Describe the neck lymphatic system
- Deep Jugular Chain: superior, middle, and inferior groups; jugulodigastric node is located at the junction of the posterior belly of the digastric muscle and the deep jugular chain; receive drainage from the parotid, retropharyngeal, spinal accessory (drain the upper retropharyngeal and parapharyngeal nodes), superficial cervical (drain the parotid, retroauricular, and occipital nodes), paratracheal, and submandibular nodes
- Jugular Trunk: drains the deep jugular drain at the root of the neck, drains into the internal jugular or subclavian vein (right) and the thoracic duct (left)
What are the important historical factors in the evaluation of a neck mass?
- Character of Neck Mass: onset, duration, and progression of growth, pain
- Contributing Factors: recent upper respiratory infection, sinus infection, otitis media, or other head and neck infection; exposure to pets and other animals; recent travel; exposure to tuberculosis; risk of malignancy (previous excision of skin or scalp lesions, family history of cancer, smoking and alcohol abuse, radiation therapy, other malignancies); recent trauma; immunodeficiency (risk of HIV, corticosteroids, uncontrolled diabetes); age (often infectious in children, higher risk of malignancy in adults)
- Associated Symptoms: fever, postnasal drip, rhinorrhea, sore throat, otalgia, night sweats, weight loss, malaise, dysphagia, hoarseness
- Think “KITTENS” for differential diagnosis
What are the important physical exam findings in the evaluation of a neck mass?
- Character of Neck Mass: size (normal hyperplastic nodes rarely exceed 2 cm), distribution, mobility, tenderness and fluctuance (infectious), consistency (firm, elastic, soft, compressible), solitary mass versus general cervical adenopathy, lesions and character of the overlying skin (eg, erythematous, blanching, vascular signs, fistulas, induration, radiodermatitis, necrotic)
- Physical Exam: thorough head and neck exam for primary malignancies (attention to nasopharynx, oral cavity, base of tongue, tonsilar fossa, nasal cavity, external ear canal, scalp, thyroid, and salivary glands); palpate other lymphatic sites (eg, inguinal, axillary, supraclavicular); palpate thyroid gland, liver, and spleen (lymphoma, mononucleosis); auscultation for vascular abnormalities
Differential diagnosis for neck masses?
“KITTENS”
K - Congenital
- Branchial cleft cysts
- Cystic hygromas
- Teratomas and dermoid cysts
- Thyroglossal duct cyst
- External laryngoceles
Infectious & Iatrogenic
- Bacterial or viral lymphadenitis
- Tuberculosis
- Cat scratch disease
- Syphilis
- Atypical mycobacteria
- Persistent generalized lymphadenopathy
- Mononucleosis
- Sebaceous cyst
- Deep inflammation or abscess
Toxins & Trauma
Hematoma
Endocrine
- Thymic cyst
- Thyroid hyperplasia
- Aberrant thyroid tissue
- Parathyroid cyst
Neoplasm
- Metastatic or regional malignancy
- Thyroid neoplasia
- Lymphoma
- Hemangiomas
- Salivary gland tumors
- Vascular tumors
- Neurogenic tumors
- Lipomas
Systemic
- Granulomatous diseases
- Laryngoceles
- Plunging ranula
- Kawasaki disease
Describe general features of Branchial Cleft Anomalies
Pathophysiology
developmental alterations of the branchial apparatus
results in cysts (no opening), sinuses (single opening to skin or digestive tract), or fistulas (opening to skin and digestive tract)
Symptoms
neck mass in anterior neck (anterior to SCM, deep to platysma); may have an associated subcutaneous palpable cord; fistulas and sinuses may express mucoid discharge; secondary infections cause periodic fluctuation of size, tenderness, and purulent drainage
Diagnosis
CT with contrast (may consider injecting contrast into fistula), laryngoscopy to visualize internal opening
Histopathology
lined by squamous epithelium
Describe the features of a First Branchial Cleft Cyst
Symptoms
usually presents as a preauricular cyst (may also be infra- or postauricular), opening within external auditory canal
Types
- Type I: ectodermal elements only; duplicated external auditory canal; typically begin periauricularly, pass lateral (superior) to facial nerve, parallel the external auditory canal, and end as a blind sac near the mesotympanum
- Type 2: more common; ectodermal and mesodermal elements; duplicated membranous external auditory canal and pinna; presents near the angle of the mandible, passes lateral or medial to facial nerve, may end near or into the external auditory canal
Treatment
full excision after resolution of infection (risk of facial nerve injury), may need superficial parotidectomy, avoid incision and drainage
Describe the features of a Second Branchial Cleft Cyst
Symptoms
cyst along anterior border of the SCM (most common branchial cleft cyst)
Fistula Pathway
external opening at lower anterior neck ➝ along
carotid sheath ➝ between external and internal carotid arteries ➝ over (lateral to) hypoglossal and glossopharyngeal nerves ➝ internal opening at middle constrictors or in tonsillar fossa
- The course of the second branchial cleft cyst runs deep to second arch derivatives and superficial to third arch derivatives
Treatment
full excision after resolution of infection, avoid incision and drainage
Describe the features of a Third Branchial Cleft Cyst
Symptoms
cyst in lower anterior neck (less common)
Fistula Pathway
external opening at lower anterior neck ➝ over
(superficial to) vagus nerve and common carotid artery➝ over hypoglossal nerve ➝ inferior to glossopharyngeal nerve ➝ pierces thyrohyoid membrane ➝ internal opening atupper pyriform sinus
Treatment
full excision after resolution of infection, avoid incision and drainage
Describe the features of a Thyroglossal Duct Cyst
Pathophysiology
failure of complete obliteration of thyroglossal duct
(created from tract of the thyroid descent from the foramen cecum down to midline neck)
Symptoms
midline neck mass with cystic and solid components, elevates with tongue protrusion (attached to hyoid bone), typically inferior to hyoid bone and superior to thyroid gland, may have fibrous cord, dysphagia, globus sensation
Histopathology
lined with respiratory and squamous epithelium
Complications
rare malignant potential, secondary infection
Treatment
Sistrunk procedure (excision of cyst and tract with cuff of tongue base and mid-portion of hyoid bone, 3% recurrence)
Describe the features of Cystic Hygromas
aka Lymphangiomas
Pathophysiology
abnormal development or obstruction of jugular
lymphatics spontaneous remission is not common
Symptoms
soft, painless, multiloculated, compressible neck mass (most common located in posterior triangle); presents at birth; transilluminates; may cause stridor, dysphagia, torticollis, cyanosis, or parotid swelling
Diagnosis
CT or MRI of neck
Complications
infection, compressive effects may cause respiratory
compromise or dysphagia, facial deformity
Treatment
excision without violating important structures, difficult to excise since lesions do not follow typical anatomical planes, high rate of
recurrence
Describe the features of Thymic Cysts
Pathophysiology
remnant of third pharyngeal pouch between angle of
mandible to midline neck
Symptoms
midline neck mass, lower neck
Diagnosis
biopsy (hassall’s corpuscles), serum calcium (associated parathyroid disorders, DiGeorge’s syndrome), CT/MRI
Treatment
excision (may require thoracic surgery)
Describe the features of Dermoid Cysts and Teratomas
Pathophysiology
derived from pleuripotent embryonal crest cells
Types
- Teratomas: composed of all 3 embryologic layers
- Dermoid Cyst: ectodermal and mesodermal elements only, most common type
- Teratomoma: differentiated to organ structure (usually fatal)
- Epignathi: differentiated to body parts (usually fatal)
Symptoms
soft midline neck mass, may be associated with tufts of hair
Diagnosis
biopsy
Complications
rare malignant potential
Treatment
excision
Describe features of Congenital Torticollis
AKA Fibromatosis Colli
Pathophysiology
intrauterine or birth trauma causing muscle injury,
hematoma, and resultant fibrosis (typically of the sternocleidomastoid muscle)
Symptoms
head and neck are held to the diseased side, chin toward the healthy side, firm thickened mass confined to sternocleidomastoid muscle (may be tender)
Diagnosis
clinical history and exam
Treatment
physical therapy, observation
Describe the features of Bacterial Cervical Adenitis
Pathogens
most commonly from group A streptococci and S. aureus
Symptoms
tender, mobile cervical mass, associated with constitutional symptoms (malaise, fever), initially may present with a single discrete node before developing generalized adenopathy
Diagnosis
clinical exam, aspiration for culture and sensitivity
Complications
septic shock
Treatment
incision and drainage, antibiotic regimen
Describe the features of Cat-Scratch Disease
Pathogen
cat-scratch bacillus (bartonella henselae)
Symptoms
cutaneous lesions at primary site, tender cervical adenopathy (later becomes painless), mild fever and malaise, pustulous lesions tend to ulcerate (risk of fistula formation)
Diagnosis
culture (Warthin-Starry stain), cat-scratch antigen test, history of cat exposure
Histopathology
intracellular, gram-negative bacillus, Warthin-Starry
stain
Treatment
observation with supportive care (self-limiting), avoid incision and drainage to prevent sinus formation (may consider aspiration)
Describe features of Atypical Mycobacteria
Pathogens
Mycobacterium avium, M. scrofulaceum, M. intracellulare
- typically less virulent than M. tuberculosis; however, less responsive to antituberculosis medications
- may colonize respiratory tract
Risks
children, immunocompromised hosts, history of foreign travel
Symptoms
unilateral cervical adenopathy (adhesive to overlying skin), corneal ulceration (most common head and neck manifestation)
Diagnosis
acid-fast stain and culture, culture requires 2–4 weeks for growth, tuberculin skin testing is often negative
Treatment
complete excision (avoid incision and drainage), antibiotics (may consider rifampin to reduce the bulk of the infected node prior to excision)
Describe features of Toxoplasmosis with lymphadenopathy
- presents as an influenza-like illness in adults; congenital form presents with hydrocephalus, chorioretinitis, and intracerebral calcifications
- diagnosed with serum titers and lymph node biopsy
Describe features of Nonspecific Lymphadenitis
Pathophysiology
reactive adenitis typically secondary to a nasopharyngeal infection, may occur from any infection of the head and neck
- primary infection may have resolved with persistent, enlarged cervical lymph nodes
Symptoms
painful swelling of the cervical lymph nodes, induration, fluctuating size or tenderness
Diagnosis
clinical history and exam, must undergo a careful exam for the primary infection, open biopsy if suspect malignancy
Treatment
address primary infection; if no primary infection site may consider a trial of broad-spectrum antibiotics versus close observation
Describe features of Kawasaki Disease
AKA Mucocutaneous Lymph Node Syndrome
Pathophysiology
vasculitis of multiple organ systems
Symptoms
fever, cervical lymphadenopathy, conjunctivitis, red and dry blistering lips, desquamating rash, cervical lymphadenopathy, “strawberry tongue” (prominent papillae)
Diagnosis
clinical history and exam
Complications
associated with coronary aneurysms (acute myocardial infarction), vasculitis
Treatment
supportive therapy, high-dose gamma globulins and aspirin for complications (coronary aneurysms)
