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34 Cards in this Set
- Front
- Back
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Differential for Neck Masses
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congenital
Infection or inflammatory neoplastic |
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History: Age
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people under 40 - masses are typically infection or congenital
risk of malignancy increases with age patients over 40, assume mass is malignant until proven otherwise |
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History: Mass Growth History
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if its been there for months, with no change - benign
If it is rapidly expanding - infections or could be lymphoma if the mass flucuates over time, and increases when the patient is sick with a URI, could just be a congenital cyst |
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History: Symptoms
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Pain related to growth and expansion
Voice changes, hoarsness, dysphagia, otalgia may indicate cervical lymph node involvement from metastasis fever, night sweats, weight loss - think LYMPHOMA spiking fever - acute infection |
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History: Social history
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tobacco/alcohol/drug use
HIV status occupational history animal exposure travel history |
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Physical Exam
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do entire body workup, not just head and neck
enlargement of both left and right supraclavicular nodes may reflect thorax disease left supraclavicular node alone may represent abdominal disease (Virchow's node) |
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Lymph node location and drainage
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occipital - posterior scalp
postauricular - side scalp preauricular - ear, midface nose, and front scalp, conjuctiva Parotid - forhead middle ear, gums, parotid gland submandibular - cheek, lips, tongue, buccal mucosa submental - lower lip, floor of mouth, tongue Superficial cervical - skin, lower larynx Deep cervical - tonsils, adenoid, thyroid, esophagus, sinuses |
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Mass localization
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Preauricular and Jaw angle - consider facial nerve function
Central Neck - thyroid, or malignant tissue, or cyst anterior SCM - potential malignancy, congenital in children posterior SCM - high incidence of malignancy, especially on the right side |
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Characteristics of the Mass
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Reactive LN - mobile and firm, but not ROCK HARD, slightly tender
Rock Hard - non tender, are generally metastatic disease, and tend to be matted to underlying structures infected nodes - isolated, asymmetric, tender, warm, and erythematous soft - mobile masses are often cystic rapidly expanding - lymphoma FIrm lateral masses that move left to right but not up and down, are involved in the carotid sheath (carotid body tumor or vagal schwannoma) immotile midline mass, that elevates with swallowing indicates a thyroid source |
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Diagnostics
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mass persistent past 3 weeks, labs and xrays should be considered
Labs: CBC ESR and CRP for systemic inflammation or infection blood culture if associated with fever EBV or CMV serology Bartonella Henselae (cat scratch disease) serology |
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Imaging Neck Masses
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CT scan - first choice
MRI - if there is soft tissue or neuronal involvement ultrasound |
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Fine Needle Aspiration
(do if imaging is nondiagnostic) |
23-25 gauge needle
if its: bloody - vascular dark brown - thyroid cancer thick and yellow - mucocele turbid and yellow - branchial cleft cyst purulent - abscess |
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Referral
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To ENT or surgeon depending on presentation
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DDx
Congenital |
may present at any age
most common in children branchial cysts (first - third) due to failed obliteration of cervical sinus can cause recurrent infections or fistula to surface (depeding on fistual or not, determines age of presentation) treat by resecting |
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1st Branchial Cleft Cyst
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less than 1% of cleft abnormalities
on face around ear type 1 - duplication of auditory canal, ectodermal origin. Passes through parotid and around facial nerve. presents with fistula type 2 - more common than type 1, below mandible, has ectoderm and mesoderm. |
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2nd Branchial Cleft Cyst
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most common
between jaw and SCM sinus travels toward tonsils |
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3rd Branchial Cleft Cyst
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lower neck
anterior to SCM ends around pharynx or thyroidn membrane |
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THyroglossal Duct Cyst
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can be asymptomatic
become infected with URI's can even present after the age of 20 Sistrunk operation may contain thyroid carcinoma so inspect |
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Hemangioma
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Most common
see in infants compressible red or blue soft mass Bruit on exam likely to have hemangiomas elsewhere observe, but if you must intervene, use glucocorticoid and laser excision |
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Vascular malformations
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lymphatics common
soft and compressible can be transluminated excise, sclerotherapy, or laser |
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laryngocele
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herniation of the saccule of the larynx
presentation with hoarseness, cough, and foreign body sensation |
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ranula
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Mucocele on floor of mouth
painless and slow growing located in submentum |
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Teratoma
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Arise from pluripotential cells and contain all three germ layers
large and encapsulated, with a cystic component |
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Dermatoid cyst
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entrapment of epithelium
post trauma can be congenital (in the midline) |
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Thymic Cyst
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midline cyst,
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Reactive Viral Lymphadenopathy
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MCC lymphadenopathy
seen in children usually resolved within a week of resolution of viral infection fixed firm lymph nodes may need refferal and biopsy Mononucleosis induced lymphadenopathy in posterior triangle accompanied by axillary and inguinal lymphadenopathy tonsillar hypertrophy |
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Bacterial Lymphadenopathy
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suppurative lymphadenopathy from skin or throat infection
staph aureus and group A Strep MRSA should also be considered in hospitalized patients may needle aspiration or drainage with culture |
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Toxoplasmosis
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inadequately cooked meat or cat feces
prolonged course of fever, malaise, myalgias, sore throat, cervical lymphadenopathy |
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Francisella tularensis
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transmission from rabbits, ticks, or water
tonsilitis, pharyngitis, and painful lymphadenopathy fever, chills headache, fatigue |
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Brucellosis
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Malta fever
acquired from farm animals, butter, or milk generalized weakness, sweating chills, malaise, headache, backache, and arthralgia afternonn fever |
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Rochalimaea
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exposure to cats
lymphadenopathy, fever, malaise self limiting requires only supportive treatment treat with azithromycin |
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actinomycosis
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submandibular region
painless mass associated with dental procedures must biopsy to diagnose penicillin is first line treatment |
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Mycobacterium tuberculosis
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diffuse and bilateral lymphadenopathy
atypical mycobacteria is more common among pediatric population unilateral mass in the parotid overlying skin becomes purple |
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HIV associated lymphadenopathy
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idiopathic hyperplasia
think atypicals mycobacterium tuberculosis pneumocystis carinii, lymphoma, and Kaposi sarcoma |
