Session 1 - Cervical Lymph Nodes and Neck Lumps

Question 1

Main actions of the lymphatic system.

Answer 1

Remove excess fluid from interstitial space

Return small proteins including pathogens and fluid that leaked from capillaries.

Immune defence and immune surveillance.

Source of lymphocytes.

Question 2

Most common regions of the body where collections of lymph nodes may be palpable.

Answer 2

Neck (cervical)
Armpit (axillary)
Groin (femoral)

Question 3

Most common cause of enlarged lymph node?

Other common cause?

Answer 3

Lymphadenopathy (remember this is just a manifestation of an underlying cause)

Lymphoedema.

Question 4

Common causes of lymphadenopathy.

Answer 4

Infection (most common)

Malignancy

Question 5

Difference in representation between lymphadenopathy due to infection and malignancy.

Answer 5

Infection: A tender and mobile lump

Malignancy: Hard and non-tender + irregular lump. It can also be rubbery, mobile and fast-growing.

Question 6

What are regional and terminal lymph nodes?

Answer 6

Regional are superficial lymph nodes and terminal lymph nodes are deep nodes.

Question 7

Which lymph nodes drain to which?

Answer 7

Regional/superficial drain to deep/terminal.

Question 8

Where would accumulation of fluid in superficial fascia of the neck drain?

Answer 8

First to superficial lymph nodes and then to deep lymph nodes.

Question 9

Where would accumulation of fluid or pathology in infrahyoids, thyroid gland, larynx/trachea, pharynx/oesophagus drain to?

Answer 9

Immediately to deep node since it is already deep of superficial fascia.

Question 10

Where would you find superficial lymph nodes?

Answer 10

In superficial fascia.

Question 11

Where would you find deep lymph nodes?

Answer 11

In the carotid sheath.

Question 12

Name the superficial lymph nodes.

Answer 12

Submental LNS
Submandibular LNS
Preaurical LNS
Postaurical LNS
Occipital LNS
Superficial cervical
Posterior cervical
Anterior cervical

Question 13

How do superficial lymph nodes differ from deep lymph nodes upon examination?

Answer 13

A swelling of a superficial lymph node will be more noticeable than a swelling of a deep lymph node.

Question 14

Where can you find the deep lymph nodes?

Answer 14

Deep to sternocleidomastoid muscle and closely related to IJV and carotid sheath.

Question 15

Most important deep lymph nodes of the neck.

Answer 15

Jugulo-digastric
Jugulo-omohyoid
Supraclavicular lymph nodes

Question 16

Where would a cold sore on the inside of your bottom lip drain to? (Which lymph node might be enlarged?)

Answer 16

Submental

Question 17

A patient comes in with conjunctivitis. Which lymph nodes might be enlarged?

Answer 17

Preaurical

Question 18

Patient comes in with tonsillitis. Which lymph nodes might be enlarged?

Answer 18

Jugulo-digastric

Question 19

Patient comes in with tongue malignancy. Which lymph nodes might be enlarged?

Answer 19

Jugulo-digastric or jugulo-omohyoid

Question 20

What is Waldeyer’s ring?

Answer 20

An annular collection (ring collection) of lymphoid tissue that surrounds the upper aerodigestive tract.

Question 21

Which lymphoid tissues does the Waldeyer’s ring consist of?

Answer 21

Pharyngeal tonsil (adenoids)
Tubal tonsil
Palatine tonsil (source of tonsillitis)
Lingual tonsils (found at the base of the tongue)

Question 22

What history is important in dx diagnosis of neck lumps?

Answer 22

Age
Duration
Progression
Associated symptoms and signs

Question 23

Why is age important?

Answer 23

Infective/inflamed neck lumps are most common in children. (More retropharyngeal space and less likely to be malignancy)

In elderly people there is an increasing probability that a neck lump will be due to malignancy.

Question 24

Upon examination, what is important in dx diagnosis of neck lumps?

Answer 24

Location
Movement upon swallowing or sticking out tongue
Palpation (Does it feel superficial or deep, is it hard/soft/smooth or irregular, is it fixed, tender, or and overlying skin changes?)

Question 25

Possible causes of neck lumps.

Answer 25

Superficial likes sebaceous cyst, dermoid cyst, lipoma or skin abscess. Inflammatory or infective lymph node like tonsillitis or mouth ulcer. Congenital lesions like thyroglossal duct cysts or branchial cysts. Thyroid pathology Primary or secondary malignancies Salivary gland pathology TB, HIV etc...

Question 26

Common midline neck lumps.

Answer 26

Dermoid cyst Thyroglossal duct cyst Thyroid gland pathology

Question 27

Common lateral neck lumps.

Answer 27

Branchial cyst | Salivary gland pathology

Question 28

What is a dermoid cyst?

Answer 28

A congenital cyst of epithelial origin. Usually fixed by surgery and will not move upon swallowing. Most commonly appears in early childhood.

Question 29

What is a thyroglossal duct cyst?

Answer 29

A congenital cyst formed upon the development of the thyroid gland at the base of the tongue. Usually midline and will move upon protrusion of tongue or swallowing.

Question 30

Red flags for lymphadenopathy.

Answer 30

Persisting over 6 weeks Fixed, hard and irregular Rapidly growing in size Associated with generalised lymphadenopathy Associated systemic signs and symptoms like weight loss and night sweats. Associated with a persistent (unexplained) change in voice/hoarseness or difficulty swallowing.

Question 31

What is usually the first-line imaging choice for investigating a neck lump?

Answer 31

Ultrasound.

Question 32

The jugulo-omohyoid node is mainly associated with what lymph drainage?

Answer 32

``` Tongue Oral cavity Trachea Oesophagus Thyroid gland ```

Question 33

What can malignancies of the abdomen and thorax result in? (Think lymph nodes)

Answer 33

Enlargement of supraclavicular lymph nodes.

Question 34

Drainage of fluid from abdomen and thorax all the way to venous circ.

Answer 34

Supraclavicular lymph nodes to thoracic duct into left subclavian vein.

Question 35

Examples of midline lumps.

Answer 35

Dermoid cysts Thyroglossal cyst Thyroid lump Lymphadenopathy

Question 36

Examples of lateral neck lumps of the submandibular triangle.

Answer 36

``` Reactive lymphadenopathy (younger age) Submandibular gland disease ```

Question 37

Examples of lateral neck lumps of the anterior triangle.

Answer 37

``` Reactive lymphadenopathy Neoplastic lymphadenopathy Branchial cyst Thyroid masses Parotid gland disease Paraganglioma Laryngocoele Cystic hygroma/lymphangioma Carotid bulb ```

Question 38

Examples of lateral neck lumps of the posterior triangle.

Answer 38

Reactive lymphadenopathy Neoplastic lymphadenopathy Lipoma Cervical rib

Question 39

Characteristics of haemangiomas and lymphangiomas.

Answer 39

Congenital lesions usually present within first years of life. Haemangiomas may spontaneously resolve. Lympangiomas are often soft, doughy, and ill-defined and may present with pressure effects. Haemangiomas often appear bluish.

Question 40

Treatment of haemangiomas.

Answer 40

Surgical treatment is most commonly reserved for lesions with rapid growth involving vital structures in case medical therapy.

Question 41

Treatment of lymphangiomas.

Answer 41

Injection with picibanil or excision for easily accessible lesions or those affecting vital functions.

Question 42

Characteristics of sebaceous cysts.

Answer 42

Most often in older people. Slow growing usually. Can be painful if infected. Biopsy confirms diagnosis.

Question 43

Characteristics of branchial cleft cysts.

Answer 43

Present as a smooth, fluctuant mass. Often appear rapidly after upper respiratory tract infection. Treatment is usually control of infection.