Lec 3 Cervical lymph nodes and neck lump

Question 1

What are the lymph nodes split into?

Answer 1

Regional (superficial) or Terminal (deep)

Question 2

What are the several regional groups in the head?

Answer 2

occipital
post auricular
submandibular

Question 3

Where do the regional lymph nodes lie in the head and neck?

Answer 3

They lie superficially within the superficial cervical fascia.
-the regional lymph nodes can readily be palpated when they are enlarged.

Question 4

Where do the terminal lymph nodes lie in the head and neck?

Answer 4

They lie deep to the investing layer of cervical fascia.

They are mainly associated with the route of IJV in the carotid sheath in the neck.

Question 5

What are the terminal lymph nodes also referred to as?

Answer 5

They are collectively called the deep cervical nodes.

Question 6

Where the deep cervical nodes receive lymph from and what do they drain into?

Answer 6

• receive lymph from the head and neck, including lymph drained first via the regional groups.
• deep tissues of the neck such as larynx and thyroid gland drain directly to deep cervical lymph node.

Question 7

Name two of the specific lymph nodes within the deep cervical group.

Answer 7

jugulo-digastric

jugulo-omohyoid.

Question 8

Where is the jugulo-digastric node located and what is its function?

Answer 8

• also called the tonsillar node.
• located just below and behind the angle of the mandible.
• concerned with lymph drainage of the palatine tonsil, oral cavity and the tongue.

Question 9

Where is the jugulo-omohyoid node located and what is its function?

Answer 9

• -mainly associated with the lymph drainage of the tongue, oral cavity, trachea, oesophagus and the thyroid gland.
• they may be enlarged when there is an infection or disease that affects these structures.

Question 10

What happens to the jugulo-digastric node in tonsillitis and cancer?

Answer 10

• Swollen and tender in tonsillitis.

- enlarged in cancers that affect the structures it drains.

Question 11

What is another group of deep cervical lymph nodes?

Answer 11

Supraclavicular nodes

found in the root of the neck on either side.

Question 12

What is the function of the supraclavicular nodes?

Answer 12

• they can enlarge in the late stages of malignancies of the abdomen and thorax, as they receive the lymph from these areas before it drains via the thoracic duct into the venous circulation.

Question 13

What are the functions of the lymphatic system?

Answer 13

1. remove excess fluid from interstitial space -returns to venous circulation via the lymphatic system.
2. key role in immune defence and immune surveillance
   - - acts as a physical and phagocytic barrier with a source of lymphocytes.
3. Returns small proteins including pathogens and fluid that leaked from capillaries.

Question 14

What are the clinical manifestations of disease involving the lymphatic system?

Answer 14

• lymphoedema

- lymphadenopathy - these are swollen lymph nodes due to infection or malignancy (primary and secondary).

Question 15

Which regions in the body are there a collection of lymph nodes that are palpable?

Answer 15

• neck (cervical)
• Armpit (axillary)
• Groin (femoral)

Question 16

What is a very common cause of neck lump?

Answer 16

lymphadenopathy

Question 17

What are the causes of an enlarged lymph node and what would there appearance be like?

Answer 17

Infection
- tender and mobile

Malignancy

• Hard, matted and non-tender
• Rubbery, mobile and fast-growing

Question 18

What are steps taken if the lymph node is found to be enlarged?

Answer 18

• take a comprehensive history
• Examine the area of tissue it drains
• If systemic disease/ malignancy suspected then examine other lymph nodes and body systems.

Question 19

What may the patient complain of if the enlarged lymph node is caused by lymphoma?

Answer 19

night sweats

Question 20

What may the patient complain of if the enlarged lymph node is caused by a malignancy?

Answer 20

unexplained weight loss

Question 21

What are the superficial lymph nodes that drain the face, scalp and neck?

Answer 21

• auricle
• occiput
• mental protuberance - on chin
• mandible
• SCM

Question 22

What are the superficial lymph nodes in the neck and what route are they associated with?

Answer 22

Superficial cervical - External jugular vein
Posterior cervical - External jugular vein
Anterior cervical - Anterior jugular vein

Question 23

What are the possible causes of neck lump?

Answer 23

1. superficial within superficial fascia/skin –e.g sebaceous cyst, dermoid cyst, lipoma, skin abscess
2. inflammatory/ infective lymph node – e.g. tonsillitis, mouth ulcer
3. congenital lesions – e.g thyroglossal cysts, branchial cyst, laryngocoele, pharyngeal pouch
4. Thyroid pathology – malignant or benign
5. primary (lymphoma) or secondary malignant (metastatic) disease involving a lymph node –supraclavicular LNs drain thorax/ abdomen too
6. salivary gland pathology (calculus, infection, tumour)
7. other –e.g chronic infection (tuberculosis, HIV) can cause lymphadenopathy and carotid artery aneurysm.

Question 24

How do you use a history to approach a neck lump?

Answer 24

1. Age - if a child has an enlarged lymph node it is most likely secondary to infection.
2. Duration, progression, associated symptoms/ signs (including red flags).

Question 25

How do you use examination to approach a neck lump?

Answer 25

1. Relate location to knowledge of underlying structures. 2. Is it in the anterior or posterior triangle? Is it midline or laterally placed? 3. Is there movement with swallowing and sticking out tongue? 4. Palpation features - -does it feel superficial, just beneath skin and quite mobile or deeper? - -Hard/ soft/ smooth/ irregular - -Is it fixed to surrounding tissue. - -tender (inflamed/ infected lumps are likely to be painful). - -Overlying skin changes e.g. Red

Question 26

What are the types of neck lumps you can get in the midline?

Answer 26

- Dermoid cyst --> this is due to problems in the development of the skin. - congenital - ---> It is full of fluid. - Thyroglossal duct cyst - Thyroid

Question 27

What are the types of neck lumps you get laterally?

Answer 27

- Submandibular gland --> Can be inflamed or a malignancy. | - Branchial cyst --> Tends to be at the upper half of the SCM, along the anterior border.

Question 28

How do you differentiate between a thyroid lump and a thyroglossal duct cyst?

Answer 28

Thyroid - Ask to swallow --> This is because thethyroid gland is invested in pretracheal fascia which attaches it to tracheal apparatus, so when you swallow, the trachea is elevated taking the thyroid gland with it. Thyroglossal duct cyst - Ask to stick tongue out --> The thyroglossal duct will move with the tongue as it is still connected to the back of the tongue.

Question 29

What are the red flags for lymphadenopathy?

Answer 29

1. If it persists for more than 6 weeks. 2. If it is fixed, hard and irregular. 3. If it is rapidly growing in size. 4. If it is associated with generalised lymphadenopathy. 5. If it is associated with systemic signs/ symptoms such as weight loss and nigh sweats. 6. If it is associated with a persistent (unexplained) change in voice/ hoarseness or difficulty swallowing.