Neck Masses Flashcards

1
Q

What is Rosai-Dorfman Disease?

A

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
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2
Q

What is Fibromatosis colli?

A

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
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3
Q

What is Kikuchi disease?

A

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
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4
Q

List the Anterior Cervical Triangles

A

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
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5
Q

List the Posterior Cervical Triangles

A

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)
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6
Q

Describe the neck lymphatic system

A
  • 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)
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7
Q

What are the important historical factors in the evaluation of a neck mass?

A
  • 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
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8
Q

What are the important physical exam findings in the evaluation of a neck mass?

A
  • 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
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9
Q

Differential diagnosis for neck masses?

A

“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
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10
Q

Describe general features of Branchial Cleft Anomalies

A

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

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11
Q

Describe the features of a First Branchial Cleft Cyst

A

Symptoms

usually presents as a preauricular cyst (may also be infra- or postauricular), opening within external auditory canal

Types

  1. 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
  2. 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

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12
Q

Describe the features of a Second Branchial Cleft Cyst

A

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

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13
Q

Describe the features of a Third Branchial Cleft Cyst

A

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

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14
Q

Describe the features of a Thyroglossal Duct Cyst

A

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)

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15
Q

Describe the features of Cystic Hygromas

A

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

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16
Q

Describe the features of Thymic Cysts

A

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)

17
Q

Describe the features of Dermoid Cysts and Teratomas

A

Pathophysiology

derived from pleuripotent embryonal crest cells

Types

  1. Teratomas: composed of all 3 embryologic layers
  2. Dermoid Cyst: ectodermal and mesodermal elements only, most common type
  3. Teratomoma: differentiated to organ structure (usually fatal)
  4. 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

18
Q

Describe features of Congenital Torticollis

A

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

19
Q

Describe the features of Bacterial Cervical Adenitis

A

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

20
Q

Describe the features of Cat-Scratch Disease

A

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)

21
Q

Describe features of Atypical Mycobacteria

A

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)

22
Q

Describe features of Toxoplasmosis with lymphadenopathy

A
  • 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
23
Q

Describe features of Nonspecific Lymphadenitis

A

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

24
Q

Describe features of Kawasaki Disease

A

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)

25
Q

Describe features of Cervical Adenopathy in the HIV patient

A
  • Idiopathic follicular hyperplasia is the most common cause of cervical adenopathy in the HIV-infected patient
  • Higher risk for lymphoma, mycobacterium, carcinoma, tuberculosis
  • Open biopsy should be reserved for highly suspicious lesions (failed antibiotic trial, enlarging, mediastinal adenopathy, suspicious FNA, >2 cm nodes, asymmetric lesions)
26
Q

Describe features of Persistent Generalized Lymphadenopathy (PGL)

A

Pathophysiology

idiopathic lymphadenopathy, may be a direct effect of
the HIV

  • cervical adenopathy is the third most common lymphatic site (axillary and inguinal more common)

Symptoms

typically asymptomatic adenopathy

Diagnosis

based on clinical history and exam, neoplastic and infectious causes must be ruled out, must have adenopathy of 2 or more sites (extrainguinal) for greater than 3 months in the HIV patient

Histopathology Patterns

follicular hyperplasia, follicular involution
(small follicles), and lymphoid depleted (no follicles)

Treatment

observation

27
Q

What is found in and pathognomonic for a thymic cyst?

A

hassall’s corpuscles