Neck Lump (GSH)

8/11/2019 Neck Lump (GSH)

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NECK LUMP

n ppro ch to di gnosis

Gatot Sugiharto, MD, Internist

Internal Medicine DepartmentFaculty of Medicine, Wijaya Kusuma UniversitySurabaya

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An approach involves an understanding of 2basic factors that in combination will allow adiagnosis to be made.

Anatomy major structures of the neck andlymph nodesPathophysiology that may arise in the abovestructures

Introduction


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Introduction

There are many causes of lumps in the neck.The most frequently : enlarged lymph nodes ,(bacterial or viral infections), cancer ( malignancy ),or other rare causesNeck lumps in children and adults should bechecked immediately.In children, most neck lumps are caused by

treatable infections. As adults age, the likelihood of the lump being acancer increases

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http://www.nlm.nih.gov/medlineplus/ency/article/003097.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002253.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002253.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003097.htm


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ANATOMICAL STRUCTURES OF THENECK

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Major structuresLocated largely in the anterior & posteriortriangles.

The anterior borders : inferior border of themandible, the sternocleidomastoid muscle andthe midline.The posterior borders : sternocleidomastoidmuscle, the trapezius muscle and the clavicle.


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The major structures5

Anterior triangles : hyoid bone, thyroid cartilage(the Adams apple), cricothyroid membrane,cricoid cartilage and trachea.The isthmus of the thyroid gland : may bepalpated over the first 2 tracheal rings and its rightand left lobes lie over the cricoid and thyroidcartilages laterally.

A normal thyroid gland (not easily palpable)

The carotid bulbThe parotid gland (not prominent on palpation)The submandibular salivary glands (oftenpalpable in thin individuals)


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Lymph node levels of the neck13


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Lymphadenopathy15

Inflammatory diseases usually resolves within4 - 6 weeks, if persists > 6 weeks requiresfurther evaluation.

Other conditions that required furtherevaluation :

>1.5 cm in diameter, firm, rubbery lymph nodes,matted lymph nodes and nodes that are fixed orhave decreased mobility.


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HISTORY (2) 17

Rapid enlargement of lymph nodes :May occur following an URIMalignant/metastatic neck masses, as in cervical lymph nodesCommon origin : squamous cell carcinoma, > 80% are associatedwith tobacco and alcohol.

Further features of malignancy : voice change, odynophagia,dysphagia, haemoptysis and previous radiation, especially with thyroidtumours.

Additional important features : oral lesions, recent trauma, referred earpain, muffled or decreased hearing and constitutional symptoms (e.g.night sweats, anorexia, weight loss), unilateral nasal discharge orepistaxis, family history of cancer and previous tumours.


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EXAMINATION (1) 18

Examination should include the mass itself, the rest of the neck, theskin of the head and neck and the ENT system (ears, oral cavity,nasal cavity, nasopharynx, oropharynx, hypopharynx and the larynx).

In cases that is difficult to examine, patients should be referred to

specialistThe first question :

A lymph node or part of another neck structure ?

The size, consistency, tenderness and mobility of the mass Acute inflammatory : tend to be soft, tender and mobile.

Chronic inflammatory : often non-tender and rubbery and either mobile or matted.

Congenital masses : usually soft, mobile and non-tender unless infected.

Vascular masses : may be pulsatile or have a bruit.

Malignant masses : may be hard, non tender and fixed


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EXAMINATION (1) 19

The scalp and skin of the head and neck should be examinedfor primary cutaneous tumours.Recent bite marks/scratches : cat scratch disease.The ear : serous otitis media associated with anasopharyngeal carcinoma or a fistula in the external auditorycanal associated with some branchial cleft abnormalities.Cranial nerve examination is also necessary.Nasal examination : a unilateral nasal mass or dischargesuspicious of a neoplasm.The mucosa of the oral cavity/oropharynx , the lateral borderof the tongue, floor of mouth, soft palate/tonsil complex majority of oral cancers arise from these areas.Palpate the base of the tongue to exclude occult lesions.


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EXAMINATION (1) 20

Tonsil : A unilateral, asymmetrically enlarged tonsil maysuggest a neoplasm.Pushed across towards the midline by aparapharyngeal mass

Dentition : dental infection cause of cervicallymphadenitisThe major structures and lymph node levels(assisted by bimanual palpation)

A mass with swallowing movement : suggests alesion in the thyroid gland or a thyroglossal cyst


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A m id l ine neck m ass , t hy ro g los salc y s t

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PATHOLOGY/AETIOLOGY/DIFFERENTIAL DIAGNOSIS

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Is the mass single or multiple?Is it in the anterior or posterior triangle?Does it move with swallowing?

Is it solid, cystic or pulsatile?Is it midline or lateral?It is preferable to use a combination of an

anatomical and pathological approach indiagnosis, always being guided by the historyand examination


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Infectious/inflammatory vs neoplastic vscongenital

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The most important distinction to make in anadult is between an infectious/ inflammatory vsa neoplastic cause.

In a child or young adult maintain a high indexof suspicion of a congenital cause.


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Infectious/inflammatory masses 25

Cervical lymphadenitis : most common in children and adolescents.

Viral and bacterial pharyngitis : acutely swollen and tender lymph nodes,which usually return to normal within several weeks. The most commonorganism is group A beta-haemolytic streptococcus.

Cervical adenitis : infectious mononucleosis (posterior triangle) of the neck(level V), may persist for 4 6 weeks. (similar with CMV infection)

Mycobacterial infections : chronic, usually but not always, accompanied bypulmonary pathology.

Generalised lymphadenopathy including cervical nodes : early stages ofHIV infection.

Salivary gland inflammation : acute sialadenitis caused by a calculusobstructing the duct, tender, inflamed, swollen gland.

Acute parotitis due to mumps.

Chronic sialadenitis

Thyroiditis


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Infective & inflammatory 26

The most common cause is inflammatory/infective lymphadenopathy,a result of self-limited bacterial or viral infection (resolves withinweeks)

Aetiologies:Bacterial streptococcal and staphylococcal infections; mycobacterial infections,tuberculosis and atypical mycobacteria; lymphadenitis secondary to dental infectionand tonsillitis;5 unusual disorders, cat-scratch disease, actinomyces, tularaemiaViral Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus(HSV), other viruses causing URTIs, HIVParasitic toxoplasmosis,Fungal coccidiomycosis

Sialadenitis (parotid, submandibular and sublingual) due toobstruction, e.g. calculus, or infections, e.g. mumpsThyroiditis.Other inflammatory conditions (e.g. sarcoidosis) and neck abscessesare also common causes of neck masses.


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Neoplastic masses 27

Can arise from any of the tissuesBen ign :

Lipoma : the most commonParotid gland neoplasms, pleomorphic adenomas, neurin oma andschwannoma. Benign submandibular salivary gland neoplasmsThyroid nodules

Malign ant : Malignant primary tumours : from the thyroid gland, salivary glandand lymphoid tissue.Metastatic neck masses : from squamous cell carcinoma of theupper aerodigestive tract.


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Other masses29

Congenital masses : Branchial cleft cysts and fistulas,thyroglossal duct cysts, dermoid cysts, lymphangiomas (cystichygromas) congenital torticollis, teratomas and thymic tumor Vascular masses : paragangliomas and vascular

malformations (haemangioma, AV malformation, aneurysm)Traumatic masses: haematoma, false aneurysm, AV fistula.Thyroid gland masses : multinodular/difus goitre, colloidgoitre, thyroiditis,Salivary gland masses : prominence with ageing,sialadenitissialadenitis, sialolithiasis, salivary cysts (HIV) andSjgrens syndrome Parapharyngeal masses : a high neck mass and a mediallydisplaced tonsil.


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Cystic hygroma30


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A lateral n ec k m as s , b ranc h ialc y s t

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Algoritm32


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INVESTIGATION 34

Investigation is tailored to the clinical impressionIn children, incisional or excisional biopsy is preferred to fine-needleaspiration.

All thyroid and salivary gland masses need investigation as doesany mass persistent beyond 4 - 6 weeksBlood investigations : often exclude metabolic and any otheruncommon causes of neck masses.CT scanning : the best imaging technique for evaluating a neckmass

Fine-needle aspiration : a simple office procedure that is safe and isthe optimal initial method for obtaining tissue samples for diagnosticIncisional/excisional biopsy : rarely needed for diagnosis in adults,but it is often necessary for the classification of lymphoma


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INDICATIONS FOR REFERRAL 36

If the mass does not resolve within 2 - 3 weeksfollowing an antibioticMalignant tumour suspected

Mass is rapidly enlarging with or withoutinflammationMass is in the thyroid gland

Mass is in the parotid glandFixed Mass


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Neck Lump (GSH)