Throat - NECK LUMPS Flashcards
Describe the boudaries of the anterior triangle
Superiorly: Mandible
Posteriorly: SCM
Anteriorly: Midline of the neck
Contents of anteior triangle
ECA, CN 9/10/12, Submandibular + Submental nodes
Boundaries of posterior triangle
Contents of posterior triangle
CN II, cervical nerve plexus, EJV, accessory nerve
Investigation of choice for neck lumps?
First choice investigation for neck lumps= FNA + Cytology (+/- USS)
What is the differential diagnosis for midline neck masses?
Submental reactive lymphadenopathy
Plunging ranula
Thyroglossal cyst
Thyroid mass (goitre)
Pharyngeal pouch
Dermoid cysts
What are thyroglossal cysts?
Congenital cystic remnant of the thyroglossal tract (runs from foramen caecum to thyroid gland)
Presentation of thyroglossal cyst
Smooth fluctuant painless lump MOVES UP on tongue protrusion (NOTE: thyroid lumps do not move on protrusion)
May become infected and therefore become tender
Management of thyroglossal cyst
Surgical excision although chance of recurrence
Differential of thyroid mass
Single (solitary) nodule- 10% malignant
- Cyst
- Adenoma (benign)
- Malignancy
- Prominent nodule in multinodular goitre
Goitre
- Smooth non-toxic goitre- endemic
- Smooth toxic goitre- graves, De Quervain’s
- Multinodular colloid goitre- most common
- Toxic multinodular goitre
ASK YOURSELF: is thyroid smooth or nodular? Is the pateint euthyroid, thryotoxic or hypothyroid?
What are dermoid cysts
Congenital defects in fusion of the midline of the skin - Contains tissue and cells normally present in skin layers including hair follicles, sebaceous (skin oil) + sweat glands
The gland and tissue secrete their normal substances and therefore closing cyst to grow
If an u20 year old presented with a midline swelling what is it likely to be?
Dermoid cysts, doesnt move up on tongue protrusion/swallowing
What is the differential diagnosis for lateral neck masses?
Reactive lymphadenopathy Lymphoma Salivary gland enlargement Branchial cyst Cystic hygroma Carotid aneurysm Thyroid mass Cervical rib
Differentials anterior triangle lumps
LN’s
Branchial Cyst
Laryngoceles
Carotid artery aneurysm
Carotid Body Tumour
Parotid Tumour
What is a branchial cyst?
Congenital non-disappearance of the second bronchial cleft in embryonic development
Describe presentation and investigations of branchial cysts
Smooth non-tender, fluctuant swelling in anterior triangle Cyst may enlarge following URTI
FNA- creamy fluid (CHOLESTEROL CRYSTALS)
Management branchial cyst
Surgical - excision
What are laryngoceles
Uncommon cause of anterior triangle lumps
Painless and may worse on blowing
May be associated with laryngeal cancer
Describe carotid artery aneurysm
Localised pulsating and laterally expansile
What is a carotid body tumour (chemodectoma)
Tumour of carotid body chemoreceptors arising in the carotid bifurcation
Describe presentation of chemodectoma
Firm/occasionally soft + PULSATILE + non tender
Can be moved side to side but not up and down
Pressure on tumour may cause dizziness and syncope by stimulating vagal tone via carotid sinus
Suspected in any mass, just anterior to the upper 1/3rd of SCM
V rare - would be surgically excised
Differentials posterior triangle lump
Cystic Higroma
Pancoast Tumour
Cervical Ribs
Pharyngeal Pouch
What is a cystic higroma
Congenital benign proliferation of lymph vessels that is found in posterior triangle - derived from jugular lymph sac
Presentation:
- Present at birth
- Multi-cystic swelling that is fleshy + compressible (+ contains clear fluid)
- Characteristically: transluminate brightly
Cause of pancoats tumour
Apical lung cancer:
- Invades sympathetic plexus (ipsilateral Horner’s)
- +/- Brachial plexus (Arm pain)
- Recurrent laryngeal nerve (hoarse voice/bovine cough)
Differential submandibular triangle lumps
Duct calculus
Parotiditis
Pleomorphic Adenoma
Causes of enlarged salivary glands
Acute viral infection (mumps)- bilateral acute swelling
Acute bacterial infection (parotiditis)
Calculi + distal infection (submandibular)
Sjogrens syndrome -Chronic bilateral symptoms, dry eyes + mouth +/- Sjogrens
Tumours
Causes of parotiditis
Aetiology- infection, stone, tumour, viral (mumps)
Pathology- inflammation of parotid gland
Presentation- one or bilateral
Whats the 80% rule in salivary gland tumours?
80% are in parotid
80% are pleomorphic adenomas
80% are in superficial lobe
Presentation of pleomorphic adenoma
Middle age and grows slowly, hard and PAINLESS
What is the most common cause of neck swelling?
Reactive lymphadenopathy
What is the mnemonic for remembering the causes of lymphadenopathy?
Mnemonic: HODGKINS DISEASE H aematological: Hodgkins lymphoma, NHL, Leukaemia O ncological: metastases D ermatopathic lymphadenitis G aucher’s disease K awasaki disease I nfections: TB, glandular fever, Syphilis N iemann Pick disease S erum sickness - reaction to proteins in antiserum derived from a non-human animal source D rug reaction (phenytoin) I mmunological (RA) S arcoidosis E ndocrinological (Hyperthyroidism) A ngioimmunoplastic lymphadenopathy S LE E osinophilic granulomatosis
What are the features of a neck lump that would make you suspect lymphoma?
Rubbery, painless lymphadenopathy Some report lump becomes painful when drinking alcohol Associated with nights sweats and splenomegaly
What are the features of a neck lump that would make you suspect a thyroid swelling?
Moves upwards when patient swallows Symptoms of hypo- or hyper-thyroidism
What are the features of a neck lump that would make you suspect a thyroglossal cyst?
Usually midline, between isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of tongue May be painful if infected More common in patients under 20
What are the features of a neck lump that would make you suspect a pharyngeal pouch?
Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration, chronic cough and halitosis (bad breath) More common in older men
What is a pharyngeal pouch?
A pharyngeal pouch is a posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men
What are the features of a neck lump that would make you suspect a cystic hygroma?
Typically found in left posterior triangle of the neck Most are evident at birth, around 90% present before 2 years of age
What is a cystic hygroma?
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
What are the features of a neck lump that would make you suspect a branchial cyst?
Oval, mobile cystic mass Develops between sternocleidomastoid muscle and pharynx Usually present in early adulthood
What is a branchial cyst?
A congenital epithelial cyst that arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development.
What are the features of a neck lump that would make you suspect a cervical rib?
Hard, non mobile Situated above first rib
What is a cervical rib?
Extra rib which arises from the seventh cervical vertebra. Sometimes known as “neck ribs”, their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.6% (1 in 150 people) to 0.8% of the population. People may have a cervical rib on the right, left or both sides.
Which group more commonly develop a cervical rib?
Females
What is the main complications of a cervical rib?
Thoracic outlet syndrome: either compression of the brachial plexus or compression of the subclavian artery.
What are the clinical features of thoracic outlet syndrome?
Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand, near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson’s sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.
