Swelling in neck Flashcards by Amba Bhargav

Congenital causes for lump in neck?

Brachial cyst
Thyroglossal duct cyst

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What is branchial cyst?

Benign, developmental defect of branchial arches

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Why are branchial cysts prone to infections?

May have fistula - so infection can manifest.

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What may be in immediate PMH in pt presenting w/ branchial cyst?

Respiratory tract infection —> branchial cysts enlarge after a resp infection

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Epidemiology of branchial cyst? Who?

Pt is late childhood/early adulthood
Female

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Ddx for branchial cyst?

Congential: Thyroglossal duct cyst, Dermoid cyst, Vascular malformation
Inflammatory: Reactive lymphadenopathy, Lymphadenitis
Neoplastic: lymphoma, thyroid tumour, salivary gland tumour

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Inv for branchial cyst?

USS
Referral to ENT (if in GP setting)
Fine needle aspiration

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Management for branchial cyst?

Conservative
Surgical excision
Abx for any acute infection

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How does thyroglossal duct cyst arise?

Thyroid develops from floor of pharynx.
Thyroid is connected to tongue by the thyroglossal duct.
Normally TGD atrophies but sometimes persists = TGDC

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Presentation of thyroglossal duct cyst?

Pt <20yrs
Midline lump
Moves upwards on tongue protrusion
Painless usually. Painful if infected

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Management of thyroglossal duct cyst?

Surgical excision
Abx if infected

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Malignant causes of neck lumps?

Metastatic cancer
Thyroid cancer
Lymphoma

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Borders of anterior triangle of neck?

Superiorly – inferior border of the mandible (jawbone).
Laterally – anterior border of the sternocleidomastoid.
Medially – sagittal line down the midline of the neck.

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Borders of posterior triangle of neck?

Anterior – posterior border of the sternocleidomastoid.
Posterior – anterior border of the trapezius muscle.
Inferior – middle 1/3 of the clavicle.

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Name superficial lymph nodes in neck

Submental
Submandibular
Pre-auricular
Post-auricular
Occipital
Superficial cervical
Posterior cervical
Anterior cervical

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Name three deep lymph nodes in the neck

Jugulo-digastric
Jugulo-omohyoid
Supraclavicular

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Differentials for cervical lymphadenopathy?

Acute infection - viral infection, infective mononucleosis, toxoplasmosis, infected eczema

Chronic infection - TB, HIV, syphilis

Malignancy - Hodgkin’s and non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia, acute lymphoblastic leukaemia,
secondary malignancy - thyroid, nasopharyngeal, breast, lung, stomach

Other causes - RA, sarcoidosis, phenytoin reaction, Kawasaki’s syndrome

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What to ask in Hx for neck lump?

Lump:
◦ Duration
◦ Position, Mobility
◦ Pain, tender
◦ Relation to swallowing

Associated symptoms:
◦ Sore throat/Dysphagia/Odynophagia
◦ Dysphonia/Otalgia/Other neck lumps
◦ Fever, night sweats, TB contact, travel abroad
◦ Smoking, alcohol

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What examinations would you do for neck lump?

Clinical ENT examination
—> clinical neck examination - Site, size, shape
—> flexible endoscopy to visualize the nose,
nasopharynx, oropharynx, hypopharynx and larynx

Think - is it in posterior or anterior triangle? Midline or lateral placement? Movement on swallowing or tongue protrusion? Palpation features?
- feel deeper? superficial?
- hard/soft/smooth/irregular?
- fixed or mobile?
- tender? non-tender?
- overlying skin changes? redness etc

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What investigations to do for neck lump?

Bloods
◦ FBC, CRP, monospot
FNAC (fine needle aspiration cytology) - Don’t incise or excise neck mass if might be SCC
CXR/USS/CT/MRI
Endoscopy and formal biopsy of primary

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What are red flags for neck lump?

Persists 6+ weeks
Fixed, hard, irregular
Rapidly growing in size
Associated with generalised lymphadenopathy
Systemic signs- weight loss, night sweats
Change in voice/hoarseness
Dysphagia/Odynophagia

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Risk factors for head and neck cancer?

Smoking
Alcohol misuse
HPV, EBV
Radiation exposure - UV, CT scanners
Immunosuppression
Occupation - acid mists, asbestos, wood dust
FHx

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General clinical presentation of head and neck cancers?

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Hoarsness/change in voice
Throat pain
Tongue ulcers
Painless neck lump

Sx present for 3+ weeks

If tumour is endocrine in nature - have weight loss, hormonal Sx

Presentation of laryngeal cancer (to refer via 2ww)?

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Persistent, unexplained hoarseness
Unexplained lump in neck

Presentation of oral cancer (to refer for 2ww)?

Unexplained ulceration in oral cavity for 3+ weeks Persistent, unexplained lump in neck Lump on lip or in oral cavity Red/red and white patch in oral cavity - erythroplakia/erythroleukoplakia

Presentation of thyroid cancer (to refer for 2ww)?

Unexplained thyroid lump

Causes of a neck lump?

Reactive lymphadenopathy - v v common Lymphoma Thyroid swelling Thyroglossal duct cyst Pharyngeal pouch Branchial cyst Cervical rib Carotid aneurysm

Presentation of Hodgkin's lymphoma?

Lymphadenopathy - non-tender, painless, asymmetrical Systemic Sx - weight loss, pruritus, night sweats, fever Painful LN after drinking alcohol LDH raised Normocytic anaemia, eosinophilia

Name of cell characteristically seen in Hodgkin's lymphoma?

Reed-Sternberg cell

Staging for Hodgkin's and non-Hodgkin's lymphoma?

Ann-Arbor staging

Management for lymphoma?

Watchful waiting Radiotherapy Chemotherapy Flu and pneumococcal vaccine

Investigations for neck lump / suspected lymphoma

Bloods: * FBC * ESR * LDH * HIV test * blood film Procedures * Excisional node biopsy Imaging: * CT CAP * PET scan for any bone marrow involvement

Presentation of thyroid cancer?

Neck lump Compressive Sx - swallow problem, feel like being strangled Voice changes

Types of thyroid cancer?

Papillary adenocarcinoma - most common (80%) Follicular adenocarcinoma - (10%) Medullary carcinoma Anaplastic carcinoma

Investigations for thyroid cancer?

Triple assessment 1. Full Hx + Ex, 2. Imaging - USS 3. Needle biopsy - fine needle aspiration cytology

Management for thyroid cancer?

Thyroidectomy Radioactive Iodine Radiotherapy or chemotherapy

Features specific to papillary adenocarcinoma?

Age 30-40 Locally compress trachea Can met to bone and lungs

Features specific to follicular adenocarcinoma?

Common in areas of low iodine Women > men Likely to metastasise into lung and bones (rather than locally invade)

Features specific to medullary thyroid cancer?

Worse prognosis than papillary or follicular Comes from calcitonin producing C cells- so can present with hypocalcaemia and diarrhoea Mets to LN - lymphadenopathy

Features specific to anaplastic thyroid cancer?

Age 60-70 V aggressive - pt presents with rapid growing neck lump Already invaded into trachea and recurrent laryngeal nerve when presents Survival 8m - v poor.

Autoimmune condition associated with thyroid lymphoma?

Hashimoto's thyroiditis

Presentation of sialadenitis? (inflame of salivary glands - usually parotid or sub-mandibular)

Pain Tenderness Redness Localised swelling - Swelling in neck - if submandibular gland - Swelling at parotid gland if this is affected

Ddx of sialadenitis?

Reactive lymphadenopathy Malignant lymphadenopathy Tumour Sub-mandibular salivary stone

Management of sialadenitis?

Abx, oral hygiene advice Encourage salivary flow - e.g. lemon juice Associated abscess = incision and drainage

Presentation of Ludwig's angina?

Neck swelling Dysphagia Fever

Pathophysiology of Ludwig's angina?

Progressive cellulitis Invades floor of mouth and soft tissues of neck From odontogenic infection (tooth infection)—> spreads into submandibular space

Management of Ludwig's angina?

Airway obstruction can occur as a result - so this is an emergency! Need: - airway management - IV abx

Presentation of pharyngeal pouch?

Older man Midline lump Gurgles on palpation Dysphagia Regurgitation Aspiration Chronic cough Halitosis

Inv for pharyngeal pouch?

Barium swallow combined with dynamic video fluoroscopy Avoiding endoscopy due to risk of perforating the lesion

Management for pharyngeal pouch?

* If the pouch is small and asymptomatic, no treatment is necessary. * For larger or symptomatic pouches, surgical approaches may be employed such as resection of the diverticulum, or incision of the cricopharyngeus muscle.

Presentation of carotid aneurysm?

Pulsaive lateral neck mass Does not move on swallowing

How to clinically distinguish between a thyroglossal cyst and thyroid nodule?

Thyroglossal duct cyst moves upwards on tongue protrusion Thyroid nodule moves upwards on swallowing

Risks of thyroid surgery on pt who is hyperthyroid?

Thyrotoxic storm and Higher risk of bleeding

Complications of carrying on thyroid surgery on a euthyroid patient?

Bleeding Infection Damage to recurrent laryngeal nerves Hypothyroidism Hypoparathyroidism

After thyroidectomy, what blood test would you do? Symptoms to suggest this blood test being low?

Calcium Tingling around mouth and fingertips. If v v low = muscle spasms

Swelling in neck Flashcards

(55 cards)