CM- The Neck Mass

Question 1

What are the bones/cartilage landmarks of the neck?

Answer 1

1. mastoid tip- behind the ear at the top of SCM
2. madible angle
3. hyoid bone- difficult in obese/females
4. thryroid cartilage
5. cricoid cartilage- more prominent in females
6. trachea
7. C1 vertebral transverse process

Question 2

What are the glandular landmarks of the neck?

Answer 2

1. parotid- tail is anterior to SCM, posterior to mandible
2. submandibular
3. Thyroid- anterior

Question 3

What are the vessel landmarks in the neck?

Answer 3

1. Carotid: the bulb (bifurcation) is located on the center of the SCM but really can fall anywhere from cricoid to the mandible
2. External jugular vein- surface of SCM

Question 4

The ________divides the neck into anterior and posterior triangles.

Answer 4

SCM

Question 5

The anterior triangle contains what 3 subdivisions?

What nodal levels are associated with each?

Answer 5

1. submental triangle - nodal Ia
2. submaxillary/submandibular triangle- nodal Ib
3. vascular triangle - nodal II, III, IV

Question 6

What nodal levels are associated with:

1. submental triangle
2. submaxillary
3. vascular triangle
4. posterior

Answer 6

1. 1a
2. 1b
3. II, III, IV
4. V

Question 7

In addition to the 5 lymph node levels, What are the other groups of lymph nodes?

Answer 7

1. pre-auricle
2. post-auricle
3. occipital
4. superficial to SCM along ex. jugular vein
5. perifacial= along facial artery at mandible
6. supraclavicular (Virchow’s node) = on the left
7. paratracheal

Question 8

When you feel a neck mass, what is the order for what you presume it to be in adult? Children?

Answer 8

Adults:

1. tumor (carcinoma if NOT tender)
2. infection
3. developmental

Children

1. infection (reactive lymph nodes to URI, otitis)
2. developmental (branchial cleft cysts, thyroglossal duct cysts)
3. tumor (sarcoma, lymphoma)

Question 9

What is the most prominent neck feature on a male? female?

Answer 9

Male- thyroid notch, so locate and work inferior

Female - cricoid, so locate and work superior

Question 10

What cancers are likely to be correlated to the following areas of the neck?
I
II
III
IV
V
VI

Answer 10

I- skin and oral
II- oropharynx, parotid, UADT (upperaero-digestive tract)
III- UADT
IV- UADT, Delphian nodule, Thyroid 
V- nasopharynx
VI- thyroid

Question 11

What are the 4 major ways neck masses can be categorized? Give examples of each.

Answer 11

1. Normal variant
   - carotid artery
2. Congenital/developmental anomaly
   - branchial cleft cyst
   - thyroglossal duct cyst
   - vascular
   - lymphatic malformation
3. infection/inflammation
   - reactive lymphadenopathy
4. Neoplastic
   - primary= salivary gland, thyroid tumor, nerve sheath tumor
   - metastatic= from head and neck, metastatic

Question 12

Sex of the patient is only important in _____ neck masses.
Females are more likely to have _________.
Males are more prone to __________________.

Answer 12

ADULT

Females- thyroid
Males- squamous cell carcinoma

Question 13

You are examining a female patient and notice a supraclavicular node on the left. What is this node called?
Where should you search for the primary legion?

Answer 13

It is Virchow’s node- on a female look for breast and ovarian cancer

Question 14

You are examining a male patient and notice a supraclavicular node on the left. What is the node called?
Where should you search for primary legion?

Answer 14

Virchow’s node on a male you want to look for lung or prostate origins

Question 15

When taking the past medical history, it is important to ask about time of onset of the mass.

If the mass come on rapidly, it is more likely an ___________ whereas if it comes on slowly it is more likely a ____________.
If it remains stable for a long period of time it is probably________________________.
If it fluctuates it is most likely ______________.

Answer 15

Rapid = infection

Insidious = neoplasm

Stable for long period of time = benign, congenital, developmental

Fluctuating = branchial or salivary cysts

Question 16

Tobacco and alcohol are carcinogens for ___________________ of the larynx and lung.

UV radiation is a carcinogen for _______.

HIV seropositivity is a risk factor for ________ and _______.

Answer 16

Tobacco/alcohol = squamous cell carcinoma
UV = skin cancer 
HIV = parotid gland lymphoepithelial cysts and lymphoma

Question 17

Where is the likely location of the mass for:

1. epistaxis
2. dysarthria
3. trismus
4. odynophagia
5. stridor

Answer 17

1. nasal cavity
2. oral cavity
3. oropharyngeal
4. hypopharynx
5. laryngeal and/or tracheal

Question 18

A patient comes in claiming they have TMJ. You are suspcious of otalgia.
What are the possible locations of the neck mass?

Answer 18

NP
OP/OC
hypopharynx
Larynx

With referred ear pain

Question 19

A patient comes in with full hearing loss. Where is the likely neck lesion?

Answer 19

NP obstructing Eustachian tube and causing severe otitis media

Question 20

What symptoms are associated with a nose mass?

What are possible causes?

Answer 20

1. epistaxis
2. pain
3. obstruction

Caused by NP, nose, sinus lesion

Question 21

A patient comes in with dysphagia, odyngophagia, dysarthria, and trismus. Where is the mass?
What is the likely cause?

Answer 21

Mass in the OC/OP.

Caused by lesions in the OC/OP, OP, OC

Question 22

A patient comes in with dysphagia and odynophagia. Where is the likely mass?
What are the causes?

Answer 22

Hypopharynx- lesion

Question 23

A patient comes in with stridor, hoarseness, odynophagia, dysphagia. Where is the mass? What are causes?

Answer 23

Mass in the larynx caused by:

1. lesion on vocal cord
2. lesion on trachea
3. lesion spreading to hypopharynx or espophagus

Question 24

A patient comes in wheezing and with stridor. Where is their neck mass?
What are causes?

Answer 24

Trachea- obstructing lesion

Question 25

A patient comes to see you and they say they have painful submandibular gland swelling that is intermittent and exacerbated by eating. What is the most likely cause?

Answer 25

submandibular duct obstruction

Question 26

What is the mass most likely to be if it is : 1. midline 2. anterolateral 3. supraclavicular 4. I 5. II, III, IV 6. V

Answer 26

1. thyroglossal duct cyst 2. branchial cleft cyst 3. neoplasm 4. glands 5. lymph nodes 6. hemangioma, venolymphatic, lymphangioma, malformation

Question 27

Metastatic carcinoma of the UADT can be involved with bacterial superinfection, so the nodes along II, III, IV will be tender. How do you differentiate a bacterial infection from a bacterial infection WITH metastatic carcinoma?

Answer 27

Metastatic deposit will persist after the infection is treated. If the entire mass resolves with antbiotics, it is most likely JUST infection

Question 28

A person has a mass that moves with deglutition (up and down when swallowing). What type of mass is this almost definitely?

Answer 28

Thyroid mass

Question 29

A person comes in with a mass that only moves medial lateral but NOT cranial/caudal. What is the mass most likely to be?

Answer 29

A mass fixed to the carotid

Question 30

A __________should be obtained if suspicious of infection or neoplasm. _____ and ______ tests should be ordered if the mass is in VI area or if you are suspicious for lesion in these glands.

Answer 30

CBC: high WBC with lots of PMNs suggests infection low RBC suggest neoplasm Thyroid and parathyroid function tests can be order if these glands are thought to be involved

Question 31

When would you use a plain X ray for evaluating neck masses?

Answer 31

You wouldnt. They are of no value

Question 32

When would you do CXR for neck masses?

Answer 32

rule out pulmonary lesions (TB or neoplastic)

Question 33

When is it reasonable to use ultrasound for neck masses?

Answer 33

1. When cystic masses are suspected 2. to locate carotid and other structures 3. thyroid masses

Question 34

When is nuclear medicine (PET scans) used in evaluating neck masses?

Answer 34

``` Occasionally with thyroid masses: Cold nodules (decreased I uptake) are cancerous Hot nodules are hyperfunctioning and are not cancerous ```

Question 35

What is the most helpful study to evaluate neck masses and other soft tissue anatomy? What are the 2 major drawbacks?

Answer 35

CT 1. it doesn't diagnose WHAT it is, just where and what is stuck to it 2. requires good kidney function bc uses IV contrast

Question 36

What are the 2 reasons why thyroid masses are evaluated with ultrasonography and NOT usually CT?

Answer 36

1. sonogram allows FNA to occur at the same time 2. thyroid cancers are often treated with thyroidectomy AND radioactive iodine. CT with contrast saturates the thyroid/cancer with iodine, so they will not absorb as much later when iodine is being used as radioactive killer of the tumor

Question 37

When would you use angiogram for neck masses?

Answer 37

1. vascular tumors (aneurysm, hemangioma) 2. paragangliomas 3. determine if a tumor surrounding the internal carotid can be done

Question 38

What is the rule of thumb for obtaining a histologic diagnosis (biopsy) for a neck mass?

Answer 38

1. NEVER perform a biopsy until all the other diagnostic modalities have been completed 2. have an experienced head and neck surgeon perform the exam prior to biopsy

Question 39

Why must a head and neck surgeon do the biopsy of the neck?

Answer 39

1. excessive scarring can disrupt lymphatic drainage 2. future operations can be compromised otherwise 3. risk of seeding of the tumor is great