Neck and Lymph Flashcards
Normal Exam Findings (3)
- Normal texture is soft and without nodular
- Size of the lateral lobes of the thyroid may be compared to the size of the third phalanx of a child’s thumb.
- Thyroid should feel soft and is size of third phalix of child’s thumb; may not be able to feel it
Goiter
Enlargement of the thyroid –> can be euthyroid, hypothyroid or hyperthyroid
Thyroid Nodules (3)
- Nodules in children need referral to endocrine to see if they want to biopsy
- 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
- NEED TO FOLLOW UP ANY THYROID NODULES!
Congenital Neck Masses (4)
- Cystic hygroma (lymphangiomas)
- Hemangioma; can interfere with the airway; treat with beta blockers
- Branchial Cleft Cyst- Most common, 20-30%, Present in late childhood and early adulthood when acutely infected (usually gets picked up in childhood)
- Thyroglossal duct cyst - Midline lesion
Cystic hygroma (9)
- Multiloculated cystic lymphatic malformation
- Usually found by second year
- 2:1 left side (goes towards the left side)
- Discrete, soft, mobile, nontender, cystic masses in posterior triangle of neck
- Collection of lymphatic sacs that contain clear, colorless lymph
- Congenital and probably represents a cluster of lymph channels that failed to connect into the normal lymphatic pathway
- As it grows, may cause tracheal compression and stridor.
- 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
- 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
Flatulent Mass
will feel very soft and full of fluid; cystic hygroma is usually a flatulent mass
More Info From Cystic Hygroma (4)
- Located more frequently on the left side of the body.
- Diagnosed in the period immediately after birth, with large lesions being noted on prenatal ultrasonography.
- Later presentations generally follow a viral infection, which can induce significant expansion of these lesions.
- Large lesions can result in airway compromise.
Second Brachial Cleft Cyst (4)
- Most common congenital neck mass-2-3% of population
- Branchial cysts
- 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
- 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
Branchial Cleft Cyst (3)
- Presents as a solitary, painless mass in the neck of a child or a young adult
- May retract with swallowing, tends to get infected
- Typical presentation is small cartilaginous horn in lower anterior border of sternocleidomastoid
Thyroglossal Duct Cyst (8)
- Usuallyfoundbelowthelevel of hyoid bone in mid line or off center
- Seenbestwhenneckis hyperextended
- Cystmayrisewithtongue protrusion and swallowing since it is connected to base of tongue
- Usually occurs midline, right where the thyroid is
- May be attached to the tongue, so it may move when the tongue moves; Can go up and down
- If it is taken out and there is no other thyroid, the child will have hypothyroidism
- Only thyroid tissue patient has can occur anywhere from the base of tongue to diaphragm
- High incidence of thyroid carcinoma in adulthood
Lymphadenopathy
- Body has 600 lymph nodes
- Can enlarge by proliferation of normal cells; Infiltration by foreign or abnormal cells
- Cannot see the chest lymph nodes; only way you can picture lymphadenopathy in the chest is via X-RAY
Types of Lymph Nodes (5)
- Deep abdominal mesenteric nodes (lots of lymph nodes in belly) usually cannot be felt, but when they are felt it is worrisome
- 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
- 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
- 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
- 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)
How is the lymph system shaped?
Bean-shaped; Covered thickly with the fibrous capsule Inward pointing trabeculae
Cortex Part of the Lymph System (6)
- Populated with lymphocytes
- Primary resting place for B Cell • undergo mitosis and divide.
- Produce immunoglobulins
- T lymphocytes circulate lymph nodes
- Blood stream
- Lymphatic ducts
Medulla part of lymph system
Made up of macrophages attached to reticular fibers
Cervical Lymph Nodes (2)
- Tender on physical examination is a reassuring
- Diameter greater than 2 cm or that are firm and matted - More likely to be malignant
Size of the Nodule (4)
- Normal for axillary and cervical region to have up to 1 cm
- Inguinal region up to 1.5
- Epitrochlear region up to .5
- Risk of underlying malignancy: Greater than 2 cm
Location and Quality of the Nodes (5)
- Palpable node in supraclavicular fossa
- Inguinal and axillary lymph nodes less likely of
malignant disease
- Tender is more likely to be infection
- If there is hemorrhage in the node due to
malignancy, may be painful
- Nodes that are fixed and matted to each other: Cancers, Invasive inflammations like TB or sarcoidosis
Newborn Lymph Nodes (2)
- Not palpable in newborn
- Congenital lesions that can be confused include: Cystic hygroma, Branchial cleft cyst, Thyroglossal duct cyst, Cervical rib
- Lymph nodes should never be palpable in newborn, if they are, suspect HIV, syphillis, congenital infections (TORCH viruses) Toxoplasmosis, other, rubella, cytomegalovirus, and Herpes
Shotty Node (5)
- 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
Hodgkin Nodes
Hodgkin’s more indolent in course and there can be 6-12 months of lymphadenopathy
Symptoms assocaited with nodes (6)
- Night sweats
- Fever
- Weight loss
- Pruritus
- Arthralgias
- Fatigue
Anterior Triange Lymph Nodes
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
Posterior Triangle Lymph Nodes (5)
- Bounded by the sternocleidomastoid muscle, the distal two thirds of the clavicle and the posterior mid line of the neck.
- 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) - Tinnea capitis causes reactive adenopathy in posterior triangle
- Can have reactive adenopathy by pulling on the hair line too much
- Worry about adenopathy when there was no infection