Swellings of the head and neck Flashcards
Describe the anatomy of the neck
2 triangles
- Anterior = below digastric, infront of sternomastoid
- Posterior = behind sternomastoid, infront of trapezius and above clavicle
What is haematoma
Collection of blood as a result of trauma
What are pyogenic bacterial infections
Those that cause the collection and production of pus
What is lymphadenitis
Enlargement of one or more lymph nodes due to bacterial infection
What is acute pyogenic lymphadenitis
Collection of pus and enlargement of lymph nodes due to bacterial infection caused by skin infection of Staph. aureus or pharyngitis by group A strep. (occurs mainly in children) This causes swelling in cervical lymph nodes
What are suppurative bacterial infections
Those that cause exudate formation and discharge
What is sialadenitis
Inflammation of one or more salivary glands
What is suppurative sialadenitis caused by
Staph. aureus
What is tubercular CL
Acquired lymphadenopathy where the patient
- coughs blood
- has weight loss
- night sweats
- shortness of breath
- fever + tiredness
What is syphilitic CL
Acquired lymphadenopathy where the patient has - painless oral ulceration - general rash - tiredness and fever Resulting from secondary syphilis
What is German measles
Acquired lymphadenopathy where the patient has the rubella virus causing
- red rash
- fever
- swollen lymph nodes
What is infectious mononucleosis
Glandular fever caused by EBV where patient has
- sore throat
- fever
- tiredness
- enlarged lymph nodes
What is mumps
Viral infection causing
- fever
- muscle ache
- poor apetite
- swelling of the parotid salivary glands
What is orofacial granulomatosis
An immunological lymphodenopathy where there is persistent enlargement of oral soft tissues causing
- angular chelitis
- gingivitis
- swollen lips
Commonly, these patients will have Crohn’s disease
What is acute lymphoblastic leukaemia
Commonly found in children and presents as
- fever
- lethargy
- bruising and bleeding tendencies
- muscular skeletal pain
- recurrent infections
Lymphadenopathy is found on investigation and there is enlarged lymph nodes in the neck as well as hepatosplenomegaly (liver and spleen enlargement)
How does lymphoma present
Hodgkins and non-hodgkins shows painless enlargement of lymph nodes in the neck groin or armpit area as well as
- tieredness
- night sweats
- weight loss
- bone pain
- flu like symptoms
What is the most common type of head and neck cancer
Squamous cell carcinoma (because squamous epithelium lines the mouth nose and throat)
What is an epidermal cyst
A benign cyst found on the skin from ectodermal tissue which is made of a thin layer of squamous epithelium - this is on the floor of the mouth and is more prevalent in males 5-50years old
What is fibrous dysplasia
Benign body tumour occurring in craniofacial skeleton
What is a cervical rib
An additional rib arising from the 7th cervical vertebra; feels like a bony swelling in the neck
What is sialosis
Chronic bilateral diffuse non-inflammatory and non-neoplastic swelling of the parotid gland
How does connective tissue disease present in the head and neck
Swelling of the parotids/salivary glands
What type of drugs can cause lymph nodal swelling
- antimalarials
- anti seizure
What is Kawasaki disease
Where the blood vessel is inflamed (usually <5 years old) and causes
- high temperature
- rashes
- swollen neck glands
- dry and cracked lips
- red fingers, eyes and toes
What should be taken into consideration when palpating and examining a lump (10)
- Site
- Size
- Shape
- Surface (smooth or irregular)
- Texture
- Temperature
- Tenderness
- Surrounding tissue (is it attached)
- Mobility
- Drainage of lymph nodes
What are the 5 cystic lesions that can arise
- Branchial cyst
- Dermoid cyst
- Thyroglossal cyst
- Epidermal cyst
- Cystic hygroma/lymphangioma
What is a branchial cyst
Congenital epithelial cyst containing remnants from second branchial cleft within the lymph nodes on the upper part of the lateral neck beneath the anterior border of sternoclaelomastoid muscle
Describe the clinical presentation of a branchial cyst
Seen in children and adolescents, asymptomatic, un-inflamed swelling
- smooth, globular and tense
- soft or fluctuant (because it is fluid filled)
What is a thyroglossal cyst
It is an embryonic remnant of the thyroglossal duct and is due to the failure of complete descent of thyroid tissue from foramen caecum with subsequent cystification
Describe the clinical presentation of a thyroglossal cyst
Seen in children and young adults, asymptomatic or infected
- it is a midline swelling in neck above the thyroid
- in the thyroid region the swelling is usually pushed to the LHS
- the swelling moves on swallowing or tongue protrusion
What is a dermoid cyst
It is made of epidermal and dermal components (keratinocytes, hair follicles, sweat glands) and this is seen in the submandibular space (lateral neck swelling) and floor of mouth above the mylohoid muscle (double chin) or midline of neck
Describe the clinical presentation of a dermoid cyst
Swelling seen in the submandibular space (lateral neck swelling) and floor of mouth above the mylohoid muscle (double chin) or midline of neck
It is smooth, globular and tense, soft or fluctuant
What is a lymphangioma/cystic hygroma
A proliferation of sequestrated lymphatic endothelium of the jugular sac
It is a congenital lymphatic lesion usually occurring on the left posterior triangle which contains a fluid filled sac due to blockage of the lymphatic system
Describe the clinical presentation of a lymphangioma/cystic hydroma
Present at birth or manifests in infancy/childhood and is an asymptomatic un-inflamed swelling at the lower third of neck in the posterior triangle
It has a smooth, diffuse and tense surface, is spongy soft and translucent and the colour is lighter than the surrounding tissue
It is the only neck swelling that will transluminate when light is shone on it because it is fluid filled
List the head and neck lymph nodes
- Preauricular
- Posterior auricular
- Occipital
- Superficial cervical (lower ear and parotid)
- Deep cervical (head+neck, scalp, ear, tongue, trachea, nasopharynx, nasal cavities, palate, oesophagus)
- Posterior cervical
- Supraclavical
- Submandibular (cheek, side of nose, lower lip, Gump, anterior tongue)
- Submental (lower lip, floor of mouth, apex of tongue)
- Tonsillar (jugulodigastric)
- Parotid
Why do lymph nodes enlarge
- Increase in the number of cells: benign lymphocytes and macrophages in response to antigens
- Infiltration with cells
- inflammatory cells in infection = lymphadenitis
- proliferation of malignant lymphocytes/macrophages
- metastatic malignant cells
- metabolite laden macrophages (lipid storage disease)
What characteristics of enlarged lymph nodes suggest a poor prognosis
If they are hard and firm, greater than 2cm large
- further investigations should be taken
What is histoplasmosis
A fungal infection that causes cervical lymphadenopathy due to breathing in spores which can affect the lungs;
the patient presents with cough, fever, hemoptysis, tiredness, headaches and lymphadenopathy
What is Langerhan’s histocytosis
Where there is excess tissue macrophages which collect in the lymph nodes causing cervical lymphadenopathy
Which drug can cause cervical lymphadenopathy
Phenytoin
What is a mucocutaneous lymph node
= Kawasaki disease; there is swelling and inflammation of blood vessels leading to cervical lymphadenopathy and this affects children under 5years
What is sarcoidosis
This is an abnormal inflammatory response which causes collection of tissue and granulomas and can cause cervical lymphadenopathy
Describe the clinical presentation of pyogenic lymphadenopathy
It can present as single or multiple painful nodules in association with dental abscesses and these have a smooth, diffuse and tense surface and are soft when acute and not fixed to the surroundings
Describe the clinical presentation of infectious mononucleosis (viral lymphadenopathy)
Affects young adults, fever, malaise, sore throat
- firm, discrete, tender and mobile lymph nodes
- purport or petechiae in the palate
How is infectious mononucleosis diagnosed
- Positive Paul-Brunnell test
- Positive Monospot slide test
Both of these are sensitive to hetrophile antibodies and this is what EBV produces once the B lymphocytes have been infected
Describe the clinical presentation of tuberculous lymphadenopathy
Single or multiple swellings in lateral neck
- indurated, asymptomatic, firm and fixed to surrounding
- fever, malaise, night sweats, weight loss, persistent cough
- the swelling undergoes necrosis to form collar-stud abscesses
- ulcers on dorsum of tongue
How can tuberculous lymphadenopathy be diagnosed
- Ziehl-Neelsen strain (test sputum for acid fast bacilli)
- Polymerised chain reaction (PCR)
- Mantoux test (latent TB injected, a small hard lump forms when there is latent TB)
- Culture on Lowenstein Jensen medium
- Biopsy and radiographs
What are malignant lymphadenopathies
= proliferation of lymphocytes within nodal/extranodal sites
- caused by Hodgkins/Non-Hodgkin’s lymphoma
- EBV or Burkitt’s lymphoma
- HIV
Describe the clinical presentations of malignant lymphadenopathy
Arise in middle aged and elderly with exception of Burkitt’s lymphoma which is seen in children and young adults
- single or bilateral swelling in lateral neck
- asymptomatic and slowly enlarging
- firm rubbery matted lymphnodes
- fever, malaise, night sweats, weight loss
How can malignant lymphadenopathy be diagnosed
Biopsy; look for Reed-Sternberg cells (Hodgkin’s)
Burkitt’s cells = Burkitt’s lymphoma
How does metastatic carcinoma (malignant lymphadenopathy) present
Usually single but can be multiple swellings on one side of neck usually affecting middle aged and elderly
- progressive increase in size
- indurated masses, fixed to surrounding tissue, rocky hard and painless
Where do metastatic carcinomas typically affect in the head and neck lymph nodes
- Submandibular LN
2. Jugulodigastric LN
How can metastatic carcinomas be diagnosed
- biopsy shows metastatic cells
What symptoms are associated with cervical rib and why
Neurological = pain, paraesthesia, anaesthesia of forearm and hands - this is because it will commonly press on the branchial plexus
Vascular - excessive pulsation and thill in subclavian artery, arm pain, hands appear pale white and feel cold
What is a lipoma and what are the clinical features of this
Benign tumour made of fat tissue (not as common in neck)
- rare, slow growing, posterior neck
- solo, semi-fluctuant, lobulated mass
- painless and asymptomatic
- appears yellow intra-orally
Describe the manifestation of parotid lesions
A neck mass when the tail of the parotid is affected
What is a Warthin’s tumour
A parotid neoplasm which is indurated, asymptomatic, and a unilateral hard lump
What is Sjogren’s syndrome
A bilateral, diffuse parotid lesion with a soft swelling plus sicca complex - this presents as dry mouth, eyes and skin and severe tiredness
What is metabolic sialosis
A multifocal bilateral, noninflammatory, non-neoplastic enlargement of the parotid salivary gland that is painless and common in alcoholics, diabetics, anorexics and those with nutritional deficiencies
What is acute viral sialadenitis
Bilateral painful infection of the parotid gland causing systematic manifestations; fever, malaise, muscle aches, headaches, tiredness, poor apetite
What can be seen in the intraoral examination of parotitis
Pus at papilla
What is thyroid goitre
Midline neck swelling due to hyper/hypo thyroidism (can be diffuse or nodular)
What is a thyroid nodule and describe its clinical presentation
It is an overgrowth of normal thyroid tissue and presents as a firm painless midline swelling in the area of the thyroid gland
What is a carotid body tumour
A malignant proliferation of the carotid body cells (cluster of chemoreceptors and other cells) located at the bifurcation in the carotid artery
Describe the clinical presentation of carotid body tumours
They are rare and affect adults, are usually benign and present as a firm movable mass in the neck at carotid bifurcation
It is painless and pulsatile but could cause compression effects on nerves supplying the face. It is typically a unilateral swelling in the lateral neck
What is Horner’s syndrome and what is it associated with
This is where there is SNS nerve damage causing ptosis, anhydrosis and myosis
This is associated with carotid body tumours as they can lead to nerve compression
