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