Session 2 Flashcards
What is lymphadenopathy
Enlargement of a lymph node due to infection or malignancy
Lymphadenopathy can develop due to
Infection and/or inflammation (of tissues drained by that lymph node)
Malignancy (either from metastases or primary malignancy)
Most likely cause of a neck lump
Swollen lymph node secondary to recent infection
2 other causes of neck lump
Thyroid gland or congenital conditions
Characteristics of a neck lump
Location, palpation findings and associated symptoms - red flags
2 ways in which lymph nodes can be organised
Regional (superficial) and terminal (deep)
Examples of regional lymph nodes in the head and neck
Occipital, post auricular, submandibular
What do regional lymph nodes do
Drain specific areas, lie superficially within the superficial cervical fascia
Readily palpated when enlarged
Where are terminal lymph nodes and what do they do
Deep to investing layer of deep cervical fascia. Deep cervical nodes
Receive all the lymph from the head and neck, including lymph first drained by regional groups
What drain directly to deep cervical lymph nodes and why is this significant
Deep tissues and structures of neck already deep to investing layer
Larynx, thyroid gland
May first present a lump in neck due to enlarged deep cervical node
Terminal nodes are closely related to the
IJV- within carotid sheath
2 specific lymph nodes within deep cervical group
Jugulo-digastric and jugular-omohyoid
Where is the jugulo-Digastric node Located (tonsillar node), what does it drain
Just below and behind the angle of the mandible,
drains palatine tonsil, oral cavity and tongue
Which lymph node is Often swollen and tender in tonsillitis and can also become enlarged in cancers
Jugulo-Digastric (tonsillar node)
jugulo-omohyoid node is mainly associated with the lymph drainage of the
Tongue, oral cavity, trachea, oesophagus and thyroid gland
Another group of deep cervical lymph nodes of particular importance
Supraclavicular nodes found in posterior triangle, at root of neck on either side
Supraclavicular nodes enlarge when
In late stages of malignancies of the abdomen and thorax as they receive lymph from these areas before it drains via the thoracic duct into venous circulation
The arterial supply to the head and neck arises from branches of the
Right and left common carotid arteries and the vertebral arteries
Vertebral arteries are branches of the
Subclavian arteries
Vertebral arteries supply the
Posterior neck and posterior parts of brain (brain stem, cerebellum)
Vertebral artery ascends through the
Transverse foramina of the cervical vertebrae except C7, enters subarachnoid space between atlas and occipital bone
Vertebral artery route after occipital bone
Up through foramen magnum curving around medulla, joins vertebral artery from the other side to form the basilar artery
Basilar artery runs along the
Anterior aspect of brainstem (pons),
Right common carotid artery originates from the
Brachiocephalic artery behind right sternoclavicular joint
Left common carotid artery rises directly from
Arch of aorta, slightly longer as courses for 2 cm in superior mediastinum before entering neck
Each common carotid artery ascends through the neck enclosed within the
Carotid sheath
Carotid sheath is a fascial envelope enclosing the
Common carotid artery, internal carotid, internal jugular vein and vagus nerve
Where do the contents of carotid sheath lie relative to eachother
Artery lies medially within sheath whilst vein is lateral, and nerve behind and in between the vessels. Sympathetic chain lies outside of sheath, medially and behind
Common carotids most commonly terminate at the level of the
Upper border of the thyroid cartilage (C4 level), and divide into internal and external carotid arteries
What is of importance at the bifurcation of the common carotids
Internal carotid artery is more bulbous due to the carotid sinus (and carotid body),
site of carotid sinus clinical relevance
Rubbing this area firmly can alleviate supra-ventricular tachycardias (carotid massage)
Internal carotid artery is distinguished by a
Lack of branches in the neck
Internal carotid artery course
Enters base of skull through carotid canal, passes through cavernous sinus, gives branches to brain and eye
External carotid artery is major source of blood supply to the
Extra cranial structures of the head and neck- 8 branches, including facial artery (main supply for tissue of face)
Branches of the external carotid artery can be remembered by the mnemonic
Some anatomists like freaking out poor medical students
2 terminal branches of external carotid artery
Maxillary and superficial temporal arteries (artiste at a level behind neck of mandible), travel through parotid gland and provide major source of blood
Maxillary artery supplies
Parotid gland and deep tissue and bone structures of face- gives middle meningeal artery which supplies meninges and skull
Superficial temporal artery supplies
Parotid gland, tissues of scalp (joins with other branches)
Superficial temporal artery can be affected in a condition called
Temporal arthritis- form of vasculitis involving small and medium size vessels. Presents as unilateral headache and jaw claudication in older people
Most of the structures of the face drain via the
Facial vein- runs from medial angle of eye towards inferior border of mandible
Facial vein then joins the
Internal jugular vein, then connect with superior and inferior ophthalmic veins
Superior and inferior ophthalmic veins have a direct connection with the
Cavernous sinus and pterygoid venous plexus - therefore blood draining face can potentially drain intracranially as cavernous sinus drains intracranially
Implications of cavernous sinus
Infections involving face as can spread to involve intra cranial structures- e.g. septic thrombi in facial vein can travel via ophthalmic veins to cavernous sinus and cause a cavernous sinus thrombosis
Important anastomosis between extra cranial veins and intracranial veins
Veins of scalp and intra cranial (dural) venous sinuses- connected by emissary veins provide potential route for infection of scalp to spread into cranial cavity
What is this
Danger triangle- can track intra-cranially
Internal jugular vein (IJV right and left) arises as a continuous of which venous (dural) structure found within the skull
Sigmoid sinus
IJV route
Runs length of neck (within carotid sheath)- straight line running from lobule of the ear to the sternoclavicular joint
What happens to Sternocleidomastoid muscle at inferior end of IJV
Splits into clavicular and sternal heads forming a gap anterior to the vein- hence readily accessed for central lines, jugular venous pulsation can be seen
Doctors use JVP for what
Indication of the pressures within the venous circulation and right side of heart- right is favoured as straighter more vertical route into right atrium so better reflects pressures
Central lines usage
Monitoring central venous pressure, administration of drugs, ease of repeated blood sampling, temporary haemodialysis
Very unwell patients
IJV recieves blood from what other veins during its descent
Facial vein, veins draining thyroid gland and tongue
IJV ends by
Joining with the subclavian vein (behind medial need of clavicle) to form Brachiocephalic vein, which drains into superior vena cava and hence the right atrium
The External jugular vein is formed by
Joining of veins that have drained the scalp and the deep structures of the face
Runs in superficial cervical fascia of the neck
EJV relativity
Deep to platysma, superficial to Sternocleidomastoid- more readily visible than IJV
EJV terminal part
Drains into subclavian vein, after piercing investing layer of deep cervical fascia and lower end of neck
Why are the vessels of the neck important
Major vessels supplying and draining brain
Access route
Important in clinical examination
Pathology can be seen in disease or injury to these vessels
Clinical importance of inferior thyroid artery
Near to recurrent laryngeal nerve
Site of baroreceptors
Common carotid artery
What forms superior border of carotid triangle
Posterior belly of Digastric
What forms medial/inferior border of carotid triangle
Superior belly of omohyoid
What forms lateral border of carotid triangle
Medial border of SCM
Importance of carotid triangle
Bifurcation of common carotid accounts here, important clinically for surgery
Clinical significance of artery in carotid triangle
Atherosclerosis, carotid sinus massage, central pulse
Access site for vagus and hypoglossal nerves
Access site for central line placement as contains internal jugular vein
Atherosclerosis in carotid triangle
Bifurcation is a common site of atherosclerosis, causes artery to narrow/stenosis, plaque rupture can release an embolus which can travel to brain, cause stroke or TIA, or transient loss of vision (Amaurosis Fugax)
What is carotid endarterectomy
Incision to neck and carotid, removal of plaque tissue and stitched back up
How does carotid sinus massage work
Increased baroreceptor activity feedback to the heart to slow down
Carotid canal is within what part of what bone
Petrous part of temporal bone
What is cavernous sinus and what runs through it
Venous type structure on upper surface of sphenoid bone
Carotid artery
CN III (oculomotor)
CN IV (trochlear)
CN VI (Abducens)
2 branches of CN V (trigeminal) (CN V1 ophthalmic and CN 2 maxillary)
What arteries supply eye
Supratrochlear, supra-orbital and central retinal
Distribution of external carotid
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Maxillary
Superficial Temporal
What happens in temporal arteritis if not treated
Permanent loss of eye sight
Layers of scalp
Skin, connective tissue, aponeurosis, loos areolar tissue, periosteum
Why does the scalp bleed
Heavy bleeding seen in scalp injuries
Artery walls held open by connective tissue and so can’t constrict
Lots of anastomoses
Lacerations deep enough to involve epicranial aponeurosis of occipitofrontalis can pull cuts open
Blood supply to scalp
Internal carotid- supraorbital and supratrochlear
superficial temporal, posterior auricular, occipital (external carotid)
Key branches of maxillary artery
Middle meningeal artery and sphenopalatine artery
Middle meningeal artery clinical relevance
Anterior branch of MMA close relation to Pterion
Pterion is thin area of bone
Fracture at this site can rupture MMA
Causes intracranial haemorrhage - extramural haemorrhage
Needs surgical treatment
Extramural haemorrhage management
Needs specialist neurosurgical treatment, craniotomy- opening of the cranium to relieve pressure, evacuate clot forming and stop bleeding
How to get estimate of right atrial pressure in cmh20
Measure height from sternal angle and add 5cm
Role of lymphatic system within the body
Remove XS fluid and pathogens from interstitial space
Returns small proteins and fluid that leaked from capillaries back into venous circulation
Role in immune defence and surveillance (physical and phagocytic Barrier, source of lymphocytes)
Describe waldeyer’s ring
Annular collection of lymphoid tissue surrounds the upper aero digestive tact- enlargement can lead to obstruction of nasal breathing, blocking of dust ACh Ian tube (leads to middle ear problems)
Describe what makes up Waldeyer’s ring from a lateral view top to bottom
Pharyngeal tonsil, tubal tonsil, palatine tonsil and lingual tonsil
What are concerning features of a lump that may suggest malignancy
Hard, tethered to surrounding tissues, painless to palpation, rubbery, fast growing
weight loss
General red flags for lymphadenopathy
Persisting for longer than 6 weeks
Fixed, hard and irregular (palpation findings)
Rapidly growing in size
Associated with generalised lymphadenopathy
Associated systemic signs and symptoms such as weight loss, night sweats
Associated with a persistent change in voice/hoarseness or difficulty swallowing
Superficial lymph nodes draining the face, scalp and neck form a
Ring from chin to occipital bone
What is Virchow’s node
Left nodes- abdominal cavity and thorax, enlarged, suggestive of gastric cancer
Movement with swallowing and movement with sticking out tongue indicate respectively
Thyroid gland pathology, thyroglossal duct cyst
What would suggest vascular lump
Pulsatile mass- carotid body tumour, carotid artery aneurysm (rare)
Salivary gland pathology
Calculus (stone), inflammation or infection, neoplasm (benign or malignant)
thyroid gland pathology
Malignant or benign neoplasm
Disease e.g grave’s
Congenital lesions
Thyroglossal duct cysts, branchial cyst, dermoid cyst, laryngocoele, cystic hygromas (posterior triangle, kids under 2), in children usually
benign lesions of skin or subcutaneous tissue
Sebaceous cyst, lipoma
midline lump suggests
Midline- thyroid gland disease, congenital lesions (dermoid cyst, thyroglossal duct cyst)
Lateral lump suggests
Lateral- salivary gland pathology A , carotid body tumour, congenital lesions (branchial cyst A, cystic hygroma P)
First line imaging choice for investigating neck lump, in order
Ultrasound
if suspicious feature can perform US guided fine needle aspiration
