Neck and Lymph

Question 1

Normal Exam Findings (3)

Answer 1

1. Normal texture is soft and without nodular
2. Size of the lateral lobes of the thyroid may be compared to the size of the third phalanx of a child’s thumb.
3. Thyroid should feel soft and is size of third phalix of child’s thumb; may not be able to feel it

Question 2

Goiter

Answer 2

Enlargement of the thyroid –> can be euthyroid, hypothyroid or hyperthyroid

Question 3

Thyroid Nodules (3)

Answer 3

1. Nodules in children need referral to endocrine to see if they want to biopsy
2. Certain females may have higher nodules that are higher risk — ex: radiation therapy for cancer as a children; or any radiation to the neck can cause scatter radiation that increases risk for thyroid disease
3. NEED TO FOLLOW UP ANY THYROID NODULES!

Question 4

Congenital Neck Masses (4)

Answer 4

1. Cystic hygroma (lymphangiomas)
2. Hemangioma; can interfere with the airway; treat with beta blockers
3. Branchial Cleft Cyst- Most common, 20-30%, Present in late childhood and early adulthood when acutely infected (usually gets picked up in childhood)
4. Thyroglossal duct cyst - Midline lesion

Question 5

Cystic hygroma (9)

Answer 5

1. Multiloculated cystic lymphatic malformation
2. Usually found by second year
3. 2:1 left side (goes towards the left side)
4. Discrete, soft, mobile, nontender, cystic masses in posterior triangle of neck
5. Collection of lymphatic sacs that contain clear, colorless lymph
6. Congenital and probably represents a cluster of lymph channels that failed to connect into the normal lymphatic pathway
7. As it grows, may cause tracheal compression and stridor.
8. Tends to be in posterior triange (sternomastocleido muscle separates these trianges); the mass tends to be in the back of the neck behind these muscles
9. Occurs in utero and as it grows it causes trachial compression and stridor

*Tends to be diagnosed in utero; pre-natal ultrasound can pick it up

Question 6

Flatulent Mass

Answer 6

will feel very soft and full of fluid; cystic hygroma is usually a flatulent mass

Question 7

More Info From Cystic Hygroma (4)

Answer 7

1. Located more frequently on the left side of the body.
2. Diagnosed in the period immediately after birth, with large lesions being noted on prenatal ultrasonography.
3. Later presentations generally follow a viral infection, which can induce significant expansion of these lesions.
4. Large lesions can result in airway compromise.

Question 8

Second Brachial Cleft Cyst (4)

Answer 8

1. Most common congenital neck mass-2-3% of population
2. Branchial cysts
3. Smooth, nontender, fluctuant masses, which occur along the lower one third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin
4. Brachial cleft cyst occurs at 2nd or 3rd brachial arches; will feel like end of pencil point- is a protruding type of mass that comes on the lower part of the sternocleidomastoid

Question 9

Branchial Cleft Cyst (3)

Answer 9

1. Presents as a solitary, painless mass in the neck of a child or a young adult
2. May retract with swallowing, tends to get infected
3. Typical presentation is small cartilaginous horn in lower anterior border of sternocleidomastoid

Question 10

Thyroglossal Duct Cyst (8)

Answer 10

1. Usuallyfoundbelowthelevel of hyoid bone in mid line or off center
2. Seenbestwhenneckis hyperextended
3. Cystmayrisewithtongue protrusion and swallowing since it is connected to base of tongue
4. Usually occurs midline, right where the thyroid is
5. May be attached to the tongue, so it may move when the tongue moves; Can go up and down
6. If it is taken out and there is no other thyroid, the child will have hypothyroidism
7. Only thyroid tissue patient has can occur anywhere from the base of tongue to diaphragm
8. High incidence of thyroid carcinoma in adulthood

Question 11

Lymphadenopathy

Answer 11

1. Body has 600 lymph nodes
2. Can enlarge by proliferation of normal cells; Infiltration by foreign or abnormal cells
3. Cannot see the chest lymph nodes; only way you can picture lymphadenopathy in the chest is via X-RAY

Question 12

Types of Lymph Nodes (5)

Answer 12

1. Deep abdominal mesenteric nodes (lots of lymph nodes in belly) usually cannot be felt, but when they are felt it is worrisome
2. Not uncommon to feel small nodes under inguinal region (birds eye, pea size); if you palpate inguinal region you can feel it (if not too muscular); easily felt in children unless they are severely obese
3. Axillary nodes found in armpit; need to relax muscles underneath; take hand and feel inward and note how deep you go; relax hand on something to get a deep feel in the axilla
4. Epitrochlear node —> follows the radial artery; best felt as arm is relaxed and slightly bent; feel where you palpate the brachial artery; enlargement of these or axillary nodes is never normal
5. Popliteal nodes can sometimes be felt if you don’t have well-developed calf muscles (medially behind the knee, felt where you feel popliteal pulses)

Question 13

How is the lymph system shaped?

Answer 13

Bean-shaped; Covered thickly with the fibrous capsule Inward pointing trabeculae

Question 14

Cortex Part of the Lymph System (6)

Answer 14

1. Populated with lymphocytes
2. Primary resting place for B Cell • undergo mitosis and divide.
3. Produce immunoglobulins
4. T lymphocytes circulate lymph nodes
5. Blood stream
6. Lymphatic ducts

Question 15

Medulla part of lymph system

Answer 15

Made up of macrophages attached to reticular fibers

Question 16

Cervical Lymph Nodes (2)

Answer 16

1. Tender on physical examination is a reassuring
2. Diameter greater than 2 cm or that are firm and matted - More likely to be malignant

Question 17

Size of the Nodule (4)

Answer 17

1. Normal for axillary and cervical region to have up to 1 cm
2. Inguinal region up to 1.5
3. Epitrochlear region up to .5
4. Risk of underlying malignancy: Greater than 2 cm

Question 18

Location and Quality of the Nodes (5)

Answer 18

1. Palpable node in supraclavicular fossa
2. Inguinal and axillary lymph nodes less likely of

malignant disease

3. Tender is more likely to be infection
4. If there is hemorrhage in the node due to

malignancy, may be painful

5. Nodes that are fixed and matted to each other: Cancers, Invasive inflammations like TB or sarcoidosis

Question 19

Newborn Lymph Nodes (2)

Answer 19

1. Not palpable in newborn
2. Congenital lesions that can be confused include: Cystic hygroma, Branchial cleft cyst, Thyroglossal duct cyst, Cervical rib
3. Lymph nodes should never be palpable in newborn, if they are, suspect HIV, syphillis, congenital infections (TORCH viruses) Toxoplasmosis, other, rubella, cytomegalovirus, and Herpes

Question 20

Shotty Node (5)

Answer 20

• Buckshot under the skin
• Nodes that small mobile, soft and non tender are called SHOTTY
• Most common between 3-5
• Freely movable
• By age of 2 all children have had an infection, with URI they get shotty node on sternocleidomastoid on anterior chain

Question 21

Hodgkin Nodes

Answer 21

Hodgkin’s more indolent in course and there can be 6-12 months of lymphadenopathy

Question 22

Symptoms assocaited with nodes (6)

Answer 22

1. Night sweats
2. Fever
3. Weight loss
4. Pruritus
5. Arthralgias
6. Fatigue

Question 23

Anterior Triange Lymph Nodes

Answer 23

Bound superiorly by mandibular border and extends along the sternocleidomastoid muscle to the mid line of the neck anteriorly.

*Can reveal reactive lymph nodes and infections

Question 24

Posterior Triangle Lymph Nodes (5)

Answer 24

1. Bounded by the sternocleidomastoid muscle, the distal two thirds of the clavicle and the posterior mid line of the neck.
2. 50% of adenopathy in posterior triangle is malignant, but the most common reason to see it there is due to head lice
   *When the lice beads on them, the child scratches a lot which brings staph into the skin and the nodes react to it (reactive adenopathy)
3. Tinnea capitis causes reactive adenopathy in posterior triangle
4. Can have reactive adenopathy by pulling on the hair line too much
5. Worry about adenopathy when there was no infection

Question 25

How to Palpate Lymph Nodes

Answer 25

Palpate with the pads of your index and middle fingers for the various lymph node groups.

Question 26

Preauricular Nodes (4)

Answer 26

* In front of theear * Drains anterior and temporal scalp, anteriorear canal and pinna, conjunctiva * Slightly anterior from this is set of carotid nodes; rarely enlarged in kids * Enlarged preauricular nodes occurs with conjuncitivits

Question 27

Postauricular Nodes (3)

Answer 27

* Behind the ear * Drains Temporal and parietal scalp * Enlarged commonly occurs with head lice

Question 28

Occipital Nodes (4)

Answer 28

* At the base of the skull * Drains the posterior scalp * Enlarges with lice * Nodes should be on both sides and travel down

Question 29

Tonsillar and Super Cervical Nodes (3)

Answer 29

1. At the angle of the jaw 2. Lower larynx, lower ear canal, and parotid 3. Right at angle of jaw = tonsilar and anteriror cervical chain follows in a line

Question 30

Submandibular Nodes (2)

Answer 30

* Under the jaw on the side * Drain cheek, nose, lips, tongue, submandibular gland, buccal mucosa

Question 31

Submental Nodes (3)

Answer 31

1. Under the jaw in the mid line 2. Drains lower lip and floor of the mouth 3. Dental disease frequently enlarges lymph nodes in submental or submandibular

Question 32

Supraclavicular Nodes (4)

Answer 32

1. In the angle of the sternomastoid and the clavicle 2. Drains the right side, mediastinum and lungs 3. Drains the left side abdomen 4. ASK CHILD TO SHRUG UPWARD AND FOREWARD WHEN ASSESSING

Question 33

Deep Cervical Chain Nodes (5)

Answer 33

1. lies below the sternomastoid 2. cannot be palpated without getting underneath the muscle 3. Hook your fingers under the anterior edge of the sternomastoid muscle 4. Drains the tonsils, adenoids, posterior scalp and neck, tongue, larynx, thyroid, palate, nose, esophagus, paranasal sinuses 5. This muscle group interferes with deep palpation of the cervical chain; to relax the muscle, you should tilt the head to the side during examining

Question 34

Where do axillary nodes drain? (4)

Answer 34

1. Arm 2. breast 3. thorax 4. neck

Question 35

Where do epitrochlear nodes drain? (1)

Answer 35

1. medial arm below elbow

Question 36

Where do inguinal nodes drain? (4)

Answer 36

1. Lower extremity, 2. genitalia, 3. buttocks, 4. abdominal wall below umbilicus

Question 37

Where do popliteal nodes drain? (1)

Answer 37

Lower leg

Question 38

Reactive Adenopathy (2)

Answer 38

1. Reaction to an infection in the drainage area 2. Pharyngitis, otitis media, conjunctivitis

Question 39

Lymphadenitis (7)

Answer 39

1. Inflamed, enlarged, tender lymph node 2. Acute onset 3. Associated with tender, erythematous , warm lymph noces with fever 4. Ultrasound identifies abscess 5. If a node gets an overwhelming amount of bacteria in it, it becomes an adentitis; it is not reacting to an infection (adenopathy), it IS an infection (lymphadenitis) 6. Lymphadenitis: the B, T, and macrophage cells became overwhelmed and the lymph is infected 7. All adenitis gets ultrasound prior to starting treatment to see if it needs to be drained (looking at abscess)

Question 40

Lymphadenopathy (2 with 3 major causes)

Answer 40

1. Less common than localized adenitis 2. Can be a sign of serious underlying systemic disease 3. Major causes of non infectious lymphadenopathy 1. Medication (as part of serum sickness; includes cephalosporins) 2. Malignancy 3. Autoimmune diseases

Question 41

Lymphadenopathy Assessment (3 with 6 differential)

Answer 41

1. Abnormal in size 2. Abnormal in number 3. Abnormal in consistency 4. Differential of Lymphadenopathy 1. Age of the patient 2. Size of the node 3. Location of the node 4. Quality of the node 5. Localized or generalized 6. Time course of the lymphadenopathy and associated symptoms