Swellings of the head and neck Flashcards
Describe the position of the 2 triangles of the neck
- Anterior - below digastric, in front of the sternomastoid
- Posterior - behind sternomastoid, in front of the trapezius, above the clavicle
What trauma can lead to acquired swelling of head/neck
Haematoma
What bacterial infections can lead to acquired swelling of the head/neck
- Pyogenic - Lymphadenitis, suppurative sialadenitis
- Tubercular CL
- Syphilitic CL
What viral infection can lead to acquired swelling the head and neck
- German measles
- Infectious mononucleosis
- Mumps
What immunologic factors can lead to acquired swelling of the head and neck
- Orofacial granulomatosis
- Crohn’s disease
What neoplastic factors can lead to acquired swelling of the head and neck
Leukaemia Lymphoma Metastatic carcinoma Squamous cell carcinoma Lipoma (benign)
What developmental factors can lead to swelling of the head and neck
- Branchial cyst
- Thyroglossal cyst
- Dermoid cyst
- Epidermal cyst
- Cystic hygroma/lymphangioma
- Fibrous dysplasia
- Cervical rib
How would you take the history of a patient with swelling in the head and neck
- Age of patient
- Date of onset of symptoms
- Duration and character of swelling
- Details of the pain experienced - duration, character, radiation, aggravating and relieving factors
- Associated symptoms
Name some of the things to note when examining a lump
Site, size, shape, surface, texture, temperature, tenderness, surrounding tissue, mobility, drainage lymph nodes
Describe the causes/aetiology for a branchial cyst
Proliferation of epithelial remnants from second
branchial cleft within lymph nodes
Describe the clinical features of a branchial cyst
- Seen in children and adolescents
- Asymptomatic, un-inflamed swelling
Describe the site, surface and consistency of a branchial cyst
Site - upper part of the lateral neck beneath anterior border of SCM
Surface - smooth, globular, tense
Consistency - Soft or fluctuant
What is the most common developmental cyst of the neck
Thyroglossal cyst
Describe the causes/aetiology of thyroglossal cysts
Failure of complete descent of thyroid tissue from
foramen caecum with subsequent cystification
Describe the clinical features of thyroglossal cysts
- Common in children and young adults
* Asymptomatic or infected
Describe the site of thyroglossal cysts
- Midline swelling in neck above level of thyroid
- In thyroid region, swelling is pushed to one side (usually left)
- Swelling often moves on swallowing or tongue protrusion
Describe the causes/aetiology of dermoid cysts
Proliferation of epithelial rests
Describe the clinical features of dermoid cysts
- Seen in young adults
- Asymptomatic, un-inflamed swelling
Describe the site of dermoid cysts
Site - Submandibular space (lateral neck swelling)
- Floor of mouth above mylohyoid muscle (double chin) or midline of the neck
Describe the surface and consistency of dermoid cysts
Surface - smooth, globular and tense
Consistency - Soft or fluctuant
Describe the causes/aetiology of lymphangioma/cystic hygroma
Proliferation of sequestrated lymphatic endothelium of the jugular sac
Describe the clinical features of lymphangioma/cystic hygroma
- Presents at birth or manifests during infancy/childhood
- Asymptomatic, un-inflamed swelling
Describe the site, surface, consistency and colour of lymphangioma/cystic hygroma
Site - Lower third of the neck
Surface - smooth, diffuse and tense
Consistency - spongy, soft and translucent
Colour - lighter than surrounding tissue
Name and many cervical lymph nodes as you can
Posterior auricular Occipital Superficial cervical Deep cervical Posterior cervical Supraclavicular Preauricular Parotid Tonsillar Submental Submandibular
What mechanisms cause lymph nodes to enlarge
- Increase in the number of cells
- Infiltration with cells
What can cause the number of lymph node cells to increase
Benign lymphocytes and macrophages in response to antigens
What can cause infiltration of the lymph nodes and cause them to enlarge
- Inflammatory cells in infection (lymphadenitis)
- In situ proliferation of malignant lymphocytes or macrophages
- Metastatic malignant cells
- Metabolite laden macrophages (lipid storage diseases)
At what time in life do lymph nodes become more dangerous
- Children/young adults – more likely to respond to minor stimuli with lymphoid hyperplasia
- Lymph nodes aged < 30 are clinically benign in 80% of cases whereas in patients over the age of 50 only 40% are benign
What types infections can lead to Cervical lymphadenopathy (CL)
- Viral upper respiratory tract
- Pyogenic infection in the local area of drainage
Name some systemic bacterial infections that can cause CL
- Tuberculosis
- Syphilis
Name some systemic viral infections that can cause CL
- Infectious mononucleosis
- Cytomegalovirus
- HIV infection
Name some systemic fungal infections that can cause CL
- Histoplasmosis
Name some systemic parasitic infections that can cause CL
Toxoplasmosis
Name some malignant disease that can cause CL
- Metastatic carcinoma
- Leukaemia
- Squamous cell carcinoma
- Lymphoma
- Langerhan’s histocytosis
What other causes are there for CL
- Drugs - Phenytoin
- Mucocutaneous lymph node syndrome (Kawasaki disease)
- Connective tissue disease
- Sarcoidosis
Describe the causes/aetiology of pyogenic lymphadenopathy
Oral inflammatory conditions esp. dental abscess
Describe the clinical features of pyogenic lymphadenopathy
Can present as single or multiple painful nodes
Describe the site, surface and consistency of pyogenic lymphadenopathy
Site - Depends on site of infection
Surface - Smooth, diffuse and tense
Consistency - soft when acute, not mixed to surrounding tissue
Describe the causes/aetiology of viral lymphadenopathy (infectious mononucleosis)
EBV - Epstein-Barr Virus
Describe the clinical features of viral lymphadenopathy (infectious mononucleosis)
- Affects young adults
- Fever, malaise and sore throat
- Lymph nodes are firm, discrete, tender and mobile
- Purpura or petechiae in the palate
What is needed for diagnosis of viral lymphadenopathy (infectious mononucleosis)
+ve paul-bunnell or mono spot slide test
Describe the causes/aetiology of Tuberculous lymphadenopathy
Mycobacterium tuberculosis transmitted by sputum
droplets from infected patients
Describe the clinical features of Tuberculous lymphadenopathy
- Single or multiple swelling in lateral neck
- Indurated, asymptomatic and firm
- Fever, malaise, night sweats, weight loss, persistent cough, SOB
- Undergoes caseous necrosis to form collar stud abscess
- Ulcer on dorsum of tongue
What is needed for diagnose of Tuberculous lymphadenopathy
- Ziehl-Neelsen stain
- PCR
- Mantoux test
- Culture on Lowenstein Jensen (LJ) medium
- Biopsy and radiograph
Describe the causes/aetiology of malignant lymphadenopathy
- Unknown (Hodgkin’s)
- Epstein-Barr virus (Burkitt’s)
- Human Immunodeficiency virus (Lymphoma)
Describe the clinical features of malignant lymphadenopathy
- Arise in middle-aged and elderly with exception of Burkitt’s seen in children and young adults
- Single or bilateral swelling in lateral neck
- Asymptomatic and slowly enlarging firm, rubbery matted lymph nodes
- Fever, malaise, night sweats and weight loss
What is needed to diagnose malignant lymphadenopathy
Biopsy - Reed-sternberg cells (Hodgkin’s)
Describe the causes/aetiology of a metastatic carcinoma
Metastatic oral cancer/nasopharyngeal lesion
Describe the clinical features of a metastatic carcinoma
- Usually single but maybe multiple (rarely bilateral)
- Seen in middle aged and elderly
- Progressive increase in size
- Indurated masses, fixed to surrounding tissue, rocky hard and painless
- Commonly affects submandibular and jugulodigastric nodes
What is needed for a diagnosis of metastatic carcinoma
- Biopsy showing metastatic cells
- Signifies advanced disease with poorer prognosis
What are the clinical features of congenital cervical rib
- Arises from the 7th cervical vertebra
- Feels like a bony swelling in the neck
- Symptoms can be neurological or vascular
What are the neurological symptoms of cervical rib
- Pain
- Paraesthesia + Anaesthesia of forearm
- Hands
What are the vascular symptoms of cervical rib
- Excessive pulsation and thrill subclavian artery
- Arm pain, arm and/or hand can appear pale white in colour and it can also feel cold
What is needed to diagnose cervical rib
CXR and x ray of the neck
What is lipoma
A benign tumour made of fat tissue
Describe the clinical features of lipoma
- Rare
- Slow-growing
- Posterior neck space is the most common site
- Soft, semi fluctuant, lobulated mass of varying size
- Painless and asymptomatic
- Intra-orally appears yellowish
What is needed to diagnose lipoma
- USS
- Biopsy
What is a thyroid nodule
Overgrowth of normal thyroid tissue
What are the clinical features of a thyroid nodule
- Firm
- Painless and asymptomatic
- Midline swelling in area of thyroid gland
- Uncommon
- 90-95% are benign, 3-5% are malignant
What is needed to diagnose a thyroid nodule
- USS
- Biopsy
What are the causes/aetiology of a carotid body tumour
Neoplastic transformation of carotid body cells
What clinical features are there for carotid body tumour
- rare, affects adults
- Usually benign, some can show malignant behaviour
- Firm, moveable mass in neck at carotid bifurcation
- Painless, pulsatile and asymptomatic
- Can cause compression effects
- Bruit and thrill may be apparent
- Unilateral swelling in lateral neck
What is needed to diagnose carotid body tumour
CT/MRI head and neck
How can you tell if a swelling is mostly developmental in origin
There are midline lesions
What do bilaterally symmetrical and unilateral swellings show about the swelling
Bilateral = anatomical structure Unilateral = neoplastic and infective
What colour and temperature indicate the presence of melanoma
Black/brown pigmentation
What does purple/red pigmentation indicate
Angioma or Kaposi sarcoma
What colour and temp are inflammatory swellings
Red and warm
What sort of movement indicates carcinomas
Fixed to adjacent structures
What does fluctuant consistency show
Cystic fluid, mucus, pus or blood present in swelling
What does a soft consistency show
Acute inflammatory swellings
What does a hard (indurated) swelling show
Carcinoma
What do well defined and poorly defined margins indicate
Well defined = benign growth
Poorly defined = malignancy
What does nodular and ulcerative surfaces indicate
carcinomas
What do uniform and smooth surface textures indicate
Cystic lesions
