Eman AlSaad 207002219

Contents :
Anatomy Definition of lateral neck swelling Pediatric lateral neck swelling : Lateral neck swelling in adult : Differential diagnoses of lateral

neck masses Clinical Approach to lateral neck mass

Hints on surface Anatomy

Anatomically the neck is the area

between the lower border of mandible, mastoid and superior nuchal line superiorly and the clavicle inferiorly

Hints on surface Anatomy

The prominent landmarks of the neck are : 1. hyoid bone, 2. Thyroid cartilage, 3. Cricoid cartilage, 4. Trachea, 5. Sternocleidomastoid muscles.

Hints on surface Anatomy

The SCM divides each side of the neck into two

major triangles, anterior and posterior .

Hints on surface Anatomy

The anterior triangle is delineated by : 1. The anterior border of the SCM
laterally, 2. The midline medially, 3. The lower border of the mandible superiorly

HI

Hints on surface Anatomy :

The borders of the posterior triangles are :
1. The posterior border of the SCM

anteriorly, 2. The clavicle inferiorly, 3. The anterior border of the trapezius muscle posteriorly

Hints on surface Anatomy :

The thyroid gland . The parotid glands . Submandibular glands . Lymph nodes .

Neck mass :
The general definition of a

neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles

Lateral Neck mass :

The lateral neck swellings are defined with

their relation to one constant landmark in the lateral neck the Sternomastoid muscle and are distributed in the various anatomical triangles

Clinical Approach to Lateral Neck mass :

History and physical examination are

fundamental to making an early and correct diagnosis.

Lateral Neck lumps in children are

common but rarely malignant, frequently representing reactive lymph node enlargement.

In adults on the other hand, benign

reactive lymph node enlargement is

An asymptomatic solitary neck mass in the lateral aspect of the neck in an adult should be considered a metastatic lymph node until proved otherwise.

Pediatric lateral neck swelling :

Pediatric lateral neck swelling :

Children commonly present with a short

history of tender, enlarged lymph nodes in the jugulodigastric area (tonsillar lymph node) suggesting an infective process, or multiple small non-tender nodes in the posterior triangle, suggesting a subclinical viral infection.

Pediatric lateral neck swelling :

Cystic swellings are usually congenital and

lymphangioma (cystic hygroma) or haemangioma.

can be due to

lymphangioma (cystic hygroma) :

lymphangioma (cystic hygroma) :

This congenital anomaly arises from the

absence of development of union between jugular lymph sacs and other lymphatics. The isolated jugular lymph sac tends to progress and may assume massive proportions even extending into the axilla .
multiloculated lymphatic lesion that can arise

anywhere, but is classically found in the left posterior triangle of the neck

lymphangioma (cystic hygroma) :

Symptoms :
A common symptom is a neck mass found at birth,

or discovered later in an infant after an upper respiratory tract infection.

Signs in physical examination : This cystic swelling is transilluminant and

is filled with clear lymphatic fluid.
It gets recurrently infected because of its

lymphoid content.

lymphangioma (cystic hygroma) :

Treatment : Treatment involves complete

excision of the abnormal tissue

whenever possible. However, cystic hygromas can often invade other neck structures, making this impossible.

Lateral neck swelling in adult :

More than 75% of lateral neck

masses in patients older than 40 years are caused by malignant tumours, and the incidence of neoplastic cervical adenopathy continues to increase with age.

Developmental : brancial cleft cyst :

is an oval, moderately movable cystic

mass that develops under the skin in the neck between the sternocleidomastoid muscle and the pharynx.
Branchial cleft cysts are remnants of

embryonic development and result from a failure of obliteration of the branchial cleft .

brancial cleft cyst :

Symptoms Most branchial cleft cysts are asymptomatic, but they may become infected . Treatment Conservative (i.e. no treatment), or surgical excision.

Infectious :
Abscess staph / strep / polymicrobial

Tx: abx +/- drainage

TB single large node, usu.

painless, cervical

Workup: PPD, rule out HIV Tx: Anti-TB meds

Cat scratch fever Bartonella

henselae

Single enlarged node Weeks to months after exposure Self limited

Mono get EBV titer

p/w cervical adenopathy

TRUMATIC :
Rarely produce a solitary mass History Hematoma (s )

Tumors
Benign
Tx: surgical excision Examples:
Lipoma Hemangioma Neuroma Fibroma Carotid

body tumor Sternomastoid Tumour

Carotid Body Tumour:

An uncommon tumour of the chemoreceptors

within the Carotid Body, it presents in mid life as an ovoid, firm, painless, potato like lump in line with the Carotid vessels at the upper border of Thyroid cartilage. It has to be differentiated from a lymph node deposit, nerve sheath tumour, and Carotid Aneurysm. Carotid Angiography, MRI and DSA are used to establish a diagnosis.
Treatment is careful dissection and excision.

Tumor :
Malignant
Primary

Salivary gland cancer (near ear or angle of mandible) Lymphoma (lateral neck ) > HODGKIN diseases SCC

Secondary

metastates

Hodgkin's lymphoma :
Hodgkin lymphoma is a neoplastic proliferation of

lymphoid cells predominantly involving lymphoid tissues. The malignant cell is the Reed-Sternberg cell. Reed-Sternberg (R-S) cells are essential to the diagnosis of Hodgkin lymphoma. The presence of R-S cells is necessary, but as R-S cells are not unique to HD, R-S cells alone are not sufficient for the diagnosis .

RS :
The ReedSternberg cell is a lymphoid cell and in most cases, is a B cell, and clonal. R-S cells are very large with abundant pale cytoplasm and two or more oval lobulated nuclei containing large nucleoli

Hodgkin's lymphoma :
is characterized by the orderly spread of

disease from one lymph node group to another and by the development of systemic symptoms with advanced disease
Patients with a history of

infectious mononucleosis due to Epstein-Barr virus may have an increased risk of HL. TREATMENT ?

Location of metastases :
Supraclavicular check for chest

malignancy
Virchows node left

supraclavicular area

Differential diagnoses of lateral neck masses

Developmental: branchial cyst,

haemangioma, laryngocoele Skin and subcutaneous tissues: sebaceous cyst, lipoma Lymph nodes: Infective:Viral: Epstein-Barr virus, HIVBacterial: staphylococcus, tuberculosis, cat scratch, brucellaProtozoa: toxoplasma, leishmaniasisFungal: histoplasmosis, blastomycosis, coccidiomycosisGranulomatous: sarcoid, foreign body reactionNeoplastic: lymphoma, metastasis

Differential diagnoses of lateral neck masses

Carotid sheath: aneurysm, carotid body

tumour, vagal or sympathetic neuroma

Salivary gland (parotid or

submandibular)Infective: sialadenitis, sialolithiasisAutoimmune: Sjgren's syndromeNeoplasticMiscellaneous: AIDS related disease

Clinical Approach
1. History . 2. Physical examination . 3. Investigation . 4. management .

History :
The evaluation of any neck mass begins with a careful

HISTORY . The

history should be taken with

because

the differential diagnosis in mind

directed questions can narrow down the diagnostic possibilities and focus subsequent investigations. For example, in younger patients, one would tend to look for congenital lesions, whereas in older adults, the first concern would always be neoplasia.

Approach of the neck mass

* Personal data :1. Age . 2. Sex . 3. Nationality .

* HPI :1. Duration . Location . 3. Size . notice . 5. Painfull / painless . masse . 2. 4. How 6. Other

Approach of the neck mass

* Systemic Review :1. Symptoms of hypo. OR hyper. THYRODISM . 2. Symptoms which indicate malignancy . 3. Respiratory Symptoms . 4. GI Symptoms . 5. Symptoms which indicate infectious / inflammatory process . ( fever , wt loss , night sweat 6. Head & Neck Symptoms . 7. Compression Symptoms .

Approach of the neck mass

* The completion of History :

1. PMH , 2. PSH . 3. FH . 4. Medication & radiation . 5. Social History : smoking , alcohol , contact with T.B. 6. Travel History .

Approach of the neck mass

* General Examinations :1. Vital Signs . 2. General appearance of the pateint . Local Examination :1. Inspection : a. site . c. color . deglutition . b. shape . d. relation to

e. relation to tongue protrusion .

Approach of the neck mass

2. Palpation : a. temperature . tenderness . c. size . surface . e. edge . consistence . g. fluctuation . pulsatility . b. d. f. h.

Approach of the neck mass

3. Percussion :
on the sternum for retrosternal extension of the thyroid .

4. Auscultation :
for bruits .

Approach of the neck mass

* Complete Head & Neck Examination :

1. look to the head for any mass or ulcer . 2. examine L.N.

Approach of the neck mass

3. examine thyroid .

4. ear , nose & throat examination .

Approach of the neck mass

5. Mouth examination .

6. laryngoscope .

Approach of the neck mass

* Systemic Examination :
1. Respiratory . 2. GI .

Approach of the neck mass

1. CBC :2. U/E :-

( infection , lymphoma ..etc. ) . ( Parathyroid ) .

3. TFT :- ( Thyroid ) . 4. PTH :- ( Parathyroid ) . 5- TB 6-CXR

Approach of the neck mass

Fine Needle Aspiration Biopsy (FNA

# Currently, FNAB is the STANDARD of diagnosis for neck masses . # Indication : Any neck mass

Approach of the neck mass

# Benefits : 1. FNAB separates inflammatory from neoplastic lesions, either benign or 2. Also may allay patient fears for malignant malignant.

disease 3. Helps the clinician differentiate carcinoma from lymphoma, # Contraindication : There are NO contraindications to FNAB.

Plz take this points to home :

Neck masses are very common Approach with History and Physical exam will commonly

lead to the correct diagnosis

75% of lateral neck masses in patients over 40 years are

caused by malignant tumours

In the absence of overt signs of infection, a lateral neck

mass is metastatic squamous cell carcinoma or lymphoma until proved otherwise inexpensive, and rapid technique that can be performed in the clinic .

Fine needle aspiration biopsy is an accurate, sensitive,

Refrences :

www.neck.co.nz/necklump/necklumpindex.ht

www.scribd.com/doc/2369226/Neck-Swelling www.ncbi.nlm.nih.gov/pubmed/15944980 www. journals.cambridge.org