The Neck Flashcards
(28 cards)
Neck Inspection
- Identify site of the lump e.g. in the midline or supraclavicuar fossa and perform a lump examination.
- Protrusion of the tongue – if the lump moves it is likely to be a thyroglossal cyst (because they are related to the base of the tongue) so proceed with this examination. A thyroid lump will not move.
- Swallowing – if the lump moves on swallowing water the lump is likely to originate in the thyroid gland.
Neck Palpation
- Palpate from the back – establish whether it is in the anterior or posterior triangle of the neck.
- Anterior triangle – bordered by the anterior border of sternocleidomastoid, the midline of the neck and the ramus of the mandible.
- Posterior triangle – bordered by posterior SCM, anterior border of trapezius and clavicle.
Differential Diagnosis
- Midline - solid - thyroid swelling or cystic - thyroglossal cyst.
- Anterior triangle - solid - lymphadenopathy or chemodectoma or cystic - branchial cyst or cold abscess (2° to TB).
- Posterior triangle - solid - lymphadenopathy or cystic - pharyngeal pouch or cystic hygroma
- Within SCM - SCM tumour
Cervical Lymph Node Palpation
Start under the chin with submental, submandibular, parotid gland and pre-auricular nodes.
Then start behind the ear with the post-auricular nodes and proceed down the anterior border of sternocleidomastoid, move laterally to infra and supraclavicular nodes and then up the posterior border of sternocleidomastoid and occipital nodes.
Thyroid Cyst
75% are in the midline, smooth and rounded and look for skin changes – can form a thyroglossal sinus with seropurulent discharge following rupture or incision.
They are rare, equally common in sexes, 40% present in 1st decade but can present at any age.
Differential diagnosis – thyroid nodules, enlarged lymph nodes other cysts – dermoid or epidermoid.
Management – surgical.
Solitary Thyroid Nodules
Commonly occur in the 4th and 5th decade of life and female to male ratio is 4:1. Only 10% are malignant in middle age but 50% are malignant in young and elderly.
Investigations – triple assessment – clinical examination, ultrasound and fine needle aspiration.
Solitary Thyroid Nodule Differential
Degenerative cysts, benign neoplasm (follicular adenoma) or malignant neoplasm (papillary, follicular, medullary, anaplastic) or metastatic disease (from breast or kidney).
Solitary Thyroid Nodule - Benign
Follicular adenoma – usually 2-4cm, encapsulated at diagnosis, undistinguishable from carcinoma on fine needle aspiration (cannot demonstrate capsule) so need to be excised.
Solitary Thyroid Nodule - Malignant
Is rare – 70% are papillary, 15% are follicular and 8% medullary.
- Papillary – paediatric – commonest in children and 90% have spread to lymph nodes.
- Follicular – fifty – mean age of presentation is 50 years and spread via bloodstream.
- Management – thyroidectomy – can be total to decrease reoccurrence or a lobectomy.
- Postoperative radio-iodine scan is used to exclude residual thyroid and metastases.
Diffuse Thyroid Enlargement
Multinodular goitre, Graves’ disease, thyroiditis e.g. De Quervains (subacute) or Hashimotos (autoimmune) or a neoplastic goitre (can be benign or malignant).
MNG - Description
The neck lump will be multinodular, may be large, there may be one nodule which is more prominent, the trachea may be deviated, there may be retrosternal extension and 40% of patients will have atrial fibrillation.
It often occurs in middle aged women, there may be a positive family history, malignant change occurs in 5% and over activity in parts can lead to mild hyperthyroidism however there are no ophthalmic complications.
Goitre - Causes
Commonest abnormality caused by iodine deficiency (commonest cause worldwide), increased physiological demand (puberty, pregnancy, lactation – commonest cause in UK) or defects in hormone production (rare).
Graves’ Management
- Medical – β-blockers e.g. propanolol to control symptoms and anti-thyroid drugs e.g. carbimazole.
- Radioiodine - treatment of choice but contraindicated in pregnancy and lactation
- Surgery – for young, pregnant patients or those who refuse radioiodine treatment – subtotal thyroidectomy or more commonly a total thyroidectomy.
Thyroidectomy Complications
- Immediate – haemorrhage (leads to airway obstruction and sutures need to be cut immediately), hoarseness or hyperthyroidism (thyroid storm).
- Early – infection, hyparathyroidism causing hypocalcaemia.
- Late – hyper or hypothyroidism.
Thyroid Eye Disease Classification
NO SPECS – 0 = normal 1 = upper lid retraction, 2 = soft tissue involvement, 3 = proptosis, 4 = exopthalmus, 5 = corneal involvement, 6 – sight loss.
Exophthalmos – caused by retro-orbital inflammation and lymphocytic infiltration leading to oedema and Lid lag – secondary to sympathetic overstimulation and restrictive myopathy.
Lymphadenopathy
- Examine as any other lump – pay particular attention to consistency – tend to be firm or rubbery, the number of palpable nodes – solitary or multiple and fixation – skin tethering to TB nodes or malignancy.
- Say – I would also like to examine the face and neck for a primary site of infection or neoplasia, the ears nose and throat including the salivary and thyroid glands and the rest of the lymphoreticular system including palpation for hepatomegaly and splenomegaly. In a female patient say I would also like to perform a breast examination as malignancy can metastasize to the neck.
Lymphadenopathy - History
Duration of lump, any pain (associated with alcohol in lymphoma), general symptoms – anorexia, weight loss or night sweats.
Social history – ethnic origin, travel history or HIV risk factors.
Lymphadenopathy - Causes
LIST – lymphoma, infection, sarcoidosis or tumours (1° or 2°).
- Infectious causes – can be divided into bacterial (tonsillitis, dental abscess or TB), viral (cytomegalovirus, infectious mononucleosis (EBV) or HIV), protozoal or toxoplasmosis.
Lymphadenopathy - Investigations
- Bloods – FBC and ESR for infection, TFTs, ACEi (raised in sarcoidosis) and Paul Bunnell test.
- Radiological – ultrasound, CT or MRI.
- Histological – fine needle aspiration or excision biopsy.
Chemodectoma
A tumour of the paraganglion cells of the carotid body located at the bifurcation of the common carotid artery.
They are usually benign (but locally invasive) but occasionally they are malignant with the potential to metastasize to local lymph nodes.
Chemodectoma - Examination
Found at the angle of the jaw, be gentle when examining in this area as pressure can induce a vasovagal attack.
Usually the lump is firm and pulsatile – due to a transmitted pulsation from adjacent carotids or a **true ** pulsation from a soft vascular tumour.
Chemodectoma - Investigation and Management
- Investigations – duplex ultrasound and CT or MRI to assess the extent of the tumour.
- Management – surgical excision or radiotherapy for patients who are unfit for surgery.
Branchial Cyst
A cyst is an abnormal sac containing gas, fluid, or semisolid fluid with an epithelial lining.
Branchial cysts are thought to develop because of failure of fusion of the embryonic second and third branchial arches.
An alternative hypothesis is an acquired condition due to cystic degeneration in cervical lymphatic tissue.
Branchial Cyst - Examination
Usually presents in the 3rd decade with a smooth, firm swelling anterior to the upper or middle third of sternocleidomastoid.
It is fluctuant on palpation, usually does not transilluminate and may be fixed to surrounding structures.
