Neck Lumps Differential Diagnosis Group 18 Nikolaos Karlagkinis Rigina Kritikou Marcel Akdenisli Apostolis Tsoutsis Jennifer Spies Andreas Gerolemou Christos Papantoniou 2 Introduction Definition Differential Diagnosis The general definition of a neck The distinguishing of a disease or a lump/mass is any abnormal condition from others that present enlargement, swelling or growth with similar signs and symptoms from the level of the base of the skull to the clavicles A variety of diseases can present as a lump or a mass on the neck. These could be inflammatory, congenital or even neoplastic lesions. Understanding the cause of the neck lump requires basic knowledge of the structures of the neck and at which level they lie. 3 Anatomy of the Neck ▹ The side of the neck presents a somewhat quadrilateral outline . ▹ It is limited above by the lower border of the body of the mandible, and an imaginary line drawn from the angle of the mandible to the mastoid process. ▹ Below, it is limited by the upper border of the clavicle. ▹ Medially, by the midline of the neck. ▹ Posteriorly, by the anterior border of the Trapezius muscle . ▹Boundaries: Anatomy of the Neck - Sternocleidomastoid anteriorly - Trapezius posteriorly 4 Posterior Triangle - Clavicle inferiorly ▹The apex of the triangle is formed by the occipital bone ▹The Roof of the posterior triangle is formed by: - Skin - Superficial fascia - Platysma muscle - Investigating layer of the deep cervical fascia Subdivisions: . Supraclavicular triangle . Occipital triangle Both of them are divided by the inferior belly of the Omohyoid muscle Anatomy of the Neck 5 Posterior Triangle Contents Nerves: Vessels: ▹ Spinal acessory nerve ▹ Arteries ▹ Branches of Cervical - Subclavian artery plexus - Transverse Cervical artery ▹ Roots and trunks of - Suprascapular artery brachial plexus. ▸ Vein ▹ Dorsal scapular - External jugular vein ▹ Long thoracic ▸ Lymph Nodes ▹ Phrenic - Occipital - Supraclavicular Clinical significance ▹ The Accessory Nerve may be damaged, while taking lymph node biopsy. ▹ The External Jugular Vein is present in a superficial location here and this makes it vulnerable to injury. Anatomy of the Neck 6 Anterior Triangle ▹ BOUNDARIES ▹ Subdivisions ▸ Anterior border of ▸ submental triangle the SCM muscle ▸ submandibular ▸ midline of the neck triangle ▸ inferior border of ▸ carotid triangle ▸ muscular triangle the mandible ▹ ROOF ▸ Skin ▸ Superfacial fascia and platysma muscle ▸ Investing layer of deep cervical fascia Anatomy of the Neck Anterior Triangle – Submental Triangle 7 ▹ Borders ▸ Body of hyoid ▸ Anterior digastric on right ▸ Anterior digastric on left ▹ Floor : Mylohyoid ▹ Roof is made of the: ▸ Skin ▸ Superficial fascia with platysmaillustrati ▸ Deep cervical fascia ons ▹ Submental triangle is unpaired ▹ Content: Anterior Jugular vein and sub-mental lymph nodes Anatomy of the Neck - Anterior Triangle – Submandibular Triangle Borders Inferior border of the mandible Arteries ▹ Lesser’s triangle is a small Posterior digastric Facial Sublingual subdivision of the submandibular Anterior digastric triangle, which aids in identifying Floor of the triangle Submental the lingual artery (especially for Hyoglossus Veins same as arteries Mylohyoid ligation) Middle constrictor Nerves Mylohyoid and hypoglossal ▹ Boundaries of Lesser’s triangle: Roof is made of the: Hypoglossal nerve Skin Structures ▸ Anterior digastric Superficial fascia with platysma Submandibular gland ▸ Posterior digastric Deep cervical fascia Inferior portion of parotid gland ▸ Submandibular triangle is paired Submandibular lymph node Anatomy of the Neck - Anterior Triangle – Carotid Triangle 9 ▹ Borders ▹ Arteries ▸ Anterior border of the ▸ Common carotid sternocleidomastoid ▸ Internal carotid ▸ Posterior digastric ▸ Superior thyroid ▸ Superior omohyoid ▸ Lingual ▸ Facial ▹ Floor ▸ Ascending ▸ Hyoglossus pharyngeal ▸ Thyrohyoid ▸ Occipital ▸ Middle ▹ Vein constrictorInferior ▸ Internal Jugalar constrictor vein Common facial Roof ▸ ▹ vein ▸ Skin ▸ Lingual Vein ▸ Superficial fascia with ▸ Superior Thyroid platysma vein ▸ Deep cervical fascia ▹ Nerves ▹ Structures ▸ Vagus ▸ Larynx ▸ Spinal Accesory ▸ Thyroid ▸ Hypoglossal ▸ Sympathetic trunk Anatomy of the Neck - Anterior Triangle – Muscular Triangle Borders Anterior border of the sternocleidomastoid Arteries Structures Superior omohyoid Superior thyroid -Strap muscles: Sternohyoid, Midline Veins Sternothyroid, Thyrohyoid Floor Inferior thyroid -Thyroid gland Sternohyoid Anterior jugular -Parathyroid gland Sternothyroid Roof Nerves: Ansa cervicalis -Larynx Skin -Trachea Superficial fascia with platysma -Esophagus Deep cervical fascia Muscular triangle is paired Process of diagnosing Head Lumps/masses 11 History Clinical Radiographic Biopsy Examination Investigations Process of diagnosis - History 12 ▹ Personal Data ▹ History of Present ▹ Systemic Review ▸ Age Illness ▸ Symptoms of hypo/hyper ▸ Sex ▸ Duration thyroidism ▸ Nationality ▸ Location ▸ Symptoms of malignancy ▸ ▸ Size Respiratory symptoms ▸ GI symptoms ▸ How notice ▸ Symptoms of inflammatory ▸ Painful/Painless process ▸ Other masses ▸ Compression symptoms ▸ Progression ▸ Trauma Process of Diagnosis – Clinical examination 13 ▹ General Examinations ▹ Complete head and neck examination ▸ Vital signs 1. Look to head for any mass or ulcer ▸ General appearance of the 2. Examination of lymph nodes patient 3. Examination of thyroid 4. Ear, nose and throat examination 5. Mouth examination ▹ Local Examination 6. Laryngoscope 1. Inspection ( site, color, shape, relation to 7. Esophagoscope deglutition, relation to tongue protrusion) 2. Palpation ( temperature, tenderness, size, surface, edge, consistency, fluctuation, pulsatility, mobility) 3. Percussion (on the sternum for retrosternal extension of the thyroid) 4. Auscultation ( for bruits) Process of Diagnosis – Radiographic Examination 14 ▹ PET and SPECT – Positron ▹ MRI – Magnetic Resonance ▹ C.T. Scan – Computed Emission Tomography and tomography Imagining Single Photon Emission ▸ Can clearly highlight ▸ Very useful to locate bony Tomography soft tissue tumors and their dimensions ▸ Useful after diagnosis to pathologies better and extensions determine the grade of a than C.T. scan tumor or distinguish between cancerous and dead/scar tissue ▹ Commonly used are also the Ultrasound for pediatric masses and thyroid masses, angiography useful for lesions encasing the carotid and vascular lesions. 15 Congenital Cysts – Thyroglossal Cyst ▹ Most common congenital neck mass ▹ Complications ▹ Diagnosis ▸ Infection -Soft tissue swelling occurs, ▸ Physical ▹ Arrested migration of thyroid along with airway obstruction and examination ▹ 50% present before age 20 trouble swallowing, rare fluid ▸ Ultrasound ▹ Midline 75% level of hyoid or near midline 25% expressions at pharynx ▸ Blood test ▸ Thyroglossal Fistula ▸ Fine needle ▹ Elevates on swallowing/protrusion of tongue ▸ Thyroglossal duct cyst carcinoma aspiration ▹ Surgery is the only treatment ▹ Dysphagia ▹ Dyspepsia 16 Congenital Cysts – Branchial Cyst ▹ Remnants of incompletely obliterated crancial clefts/pouches ▹ Located anterior and deep in to sternocleidomastoid muscle ▹ Below mandible ▹ 20% of neck masses in children ▹ Painless, asymptomatic until infection arises ▹ May have small sinus tract into tonsilar fossa ▹ Contains cholesterol crystals ▹ Persistence of 2nd branchial cleft ▹ Unlike a thyroglossal duct cyst, when swallowing, the mass should not move up or down. 17 Congenital Cysts – Sebaceous Cyst ▹ Benign, harmless growth that occurs under the skin and tends to be smooth to the touch ▹ Ranging in size, sebaceous cysts are usually found on the scalp, face, neck and ears. ▹ They are formed when the release of sebum, a medium-thick fluid produced by sebaceous glands in the skin is blocked ▹ Unless they become infected, painful or large, they do not require medical treatment because they usually go away on their own 18 Congenital Cysts – Dermoid Cysts ▹ Congenital defect that occurs during embryonic development when the skin layers do not properly grow together ▹ It is lined with epithelium that contains tissues and cells normally present in the skin layers like hair follicles, sebaceous and sweat glands ▹ These tissues secrete their substances which collect inside the cyst causing growth ▹ The mass can be easily moved beneath the skin ▹ symptoms develop only after the cyst has become infected or has grown significantly ▹ Dermoid cyst resembles thyroglossal cyst but it does not move by swallowing 19 Congenital Cysts – Thymic Cyst ▹ Thymic cysts are a rare, benign anomaly and represent 1–3% of all mediastinal masses ▹ usually asymptomatic ▹ difficult to distinguish thymic cysts from solid neoplasms of the thymus ▹ complications, such as aggravation or rupture of the cysts, malignant transformation or compression of the surrounding organs in the mediastinum, can arise in some patients ▹ For diagnosis CT scan is most commonly used 20 Congenital Cysts - Laryngocele ▹ Laryngoceles are uncommon congenital anomalies of the supraglottic larynx ▹ Form as a result of air or fluid filled dilations of the laryngeal ventricle. ▹ Classified as internal or external. Internal laryngoceles, are comprised of a collection of air or serous fluid and mucous in the anterior portion of the laryngeal ventricle. They have the potential to enlarge into the false vocal fold. Internal laryngoceles are classified as such because their sac remains within the confines of the thyroid cartilage. In contrast, as external laryngoceles