8 neck examination

Dr. Elias Areen
El Azhar university Gaza Palestine
lama el banna
faculty of dentistry
surgery

1. Physical examination of the neck Elias jan arteen 1

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13. Lymphatic drainage 13

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16. Levels (zones) of lymph nodes 16

17. Neck examination Inspection Palpation - lymph nodes - salivary glands - thyroid gland - larynx and trachea 17

18. Neck masses Inflammatory Congenital Traumatic Neoplastic 18

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20. Inflammatory neck masses Bacterial staphylococcus, streptococcus Viral Epstein- barr virus HIV Protozoal toxoplasma Fungal Granulomatous : - Cat-Scratch disease - Actinomycosis - Tuberculosis - Atypical tuberculosis 20

21. Lymphadenitis Deep neck infections: - Ledwing angina - peri tonsillar abscess - Para pharyngeal abscess - Retropharyngeal abscess 21

22. Congenital neck masses Branchial cleft cysts Thyroglossal cyst Vascular: Haemangioma and lymphangioma Dermoid cysts 22

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25. Traumatic neck masses SCM muscle hematoma (new born) Pseudoaneurysms of major vessels after blunt trauma Neuroma of nerve endings after surgery 25

26. Malignant neck tumors Lymphoma Thyroid carcinoma Salivary glands malignancies Metastatic lymph nodes Vascular Neurogenic Soft tissue tumors 26

27. Benign neck tumors Lipoma Carotid body tumor Cystic hygroma Pharyngeal pouch Sternomastoid tumor Cervical rib Salivary glands benign tumors Thyroid benign tumors 27

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29. Branchial cyst Cystic mass Behind the anterior margin of the SCM muscle, below mandible Remnant of 2nd Branchial clefts Appear at any age (mostly 15- 25) Painless swelling Hard, smooth, not very mobile Full of yellowish golden material, cholesterol crystals Can not be reduced or compressed May have small sinus tract into tonsiller fossae No associated LAP 29

30. Branchial fistula (or sinus ) First branchial fistula Second branchial fistula Third branchial fistula Fourth branchial fistula If its end is closed it is called a sinus. 30

31. Ranula Cystic swelling floor of mouth(ranula little frog) Mucus extravasations from sublingual salivary gland May extend through FOM muscles into neck “plungin g ranula” 31

32. Carotid body tumor Rare tumor of the chemoreceptor tissue of the carotid body (chemodectoma) 40 – 60 years of age Painless slowly growing pulsating lump Upper part of the ant triangle Solid, hard, pulsating spherical or irregular mass Can move from side to side but not up and down 32

33. Carotid body tumor 33

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35. Cystic hygroma (lymphangioma) Collection of lymphatic sacs which contain clear colorless lymph Congenital Present at birth or within the first years of life Commonly found at the base of the neck, occupying large space Lobulated and flattened cysts Smooth and very close to skin and contain clear fluid → transillumination 35

36. Cystic hygroma 36

37. Cyst i c hygroma 37

38. Hemangioma Capillary/ vascular hemangioma Purplish mass typical for diagnosis Can be found at any place in the body The most common tumor of the body in children(Benign) Treatment: surgery/ Laser/ Steroids 38

39. Pharyngeal pouch (Zenker’s diverticulum) Pulsion diverticulum through Killian’s dehiscence at the posterior pharyngeal wall 39

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41. Zenker diverticulum 41

42. Appears at middle age Halitosis, recurrent sore throat, regurgitation of food → coughing and choking at night Dysphagia Neck swelling usually behind the SCM below the level of the thyroid cartilage Compression causes regurgitation sounds Pharyngeal pouch (Zenker’s diverticulum) 42

43. Sternomastoid tumor Ischemic contracture of a segment of the SCM muscle A swelling of the middle third of the SCM In neonates: edema around an infracted segment of the muscle caused by birth trauma As the patient grows the muscle becomes fibrotic and contracted 43

44. SCM tumor Neck swelling at birth Torticollis Fibrosis → chronic torticollis Examine the lump, neck, head and eyes Examine for squint in straight head position (secondary torticollis) 44

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46. Cervical rib Usually detected on x-ray Sometimes there is fullness at the root of the neck Pain in C8 and T1 dermatomes and weakness of hand muscles Raynaud’s phenomenon 46

47. Cervical rib 47

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49. Thyroglossal cyst Congenital , Remnants of thyroglossal tract Mostly infrahyoid Can appear at any age (mostly 15- 30) Painless lump in the midline of the neck (75% in midline) Pain and redness if infected ( fistula) Spherical, smooth, mobile cyst in the midline Moves with swallowing and tongue protrusion Required surgery 49

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52. Aortic arch aneurysm 52

53. Thyroid gland 53

54. Neoplastic neck masses 1. Primary Thyroid neoplasms Lymphoma, Hodgkin's disease, lymphosarcoma Salivary neoplasms (parotid, Submandibular) Vascular neoplasms (carotid body tumor, glomus tumors) Schwannoma Lipoma 54

55. Head and neck cancers 6 th most common cancer overall H&N SCC 5% of all cancers SCC most common upper aerodigestive malignancy Smoking and ETOH 50% of head and neck cancer occur in oral cavity Multidisciplinary approach 55

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57. 2. Metastatic lymph nodes (Enlarged lymph node- Asymmetric- Adult) R emember P rimary cervical malignancy is rare and almost all malignant cervical tumors except for lymphomas are metastatic 57

58. Primary lymph node neoplasm Most common is lymphoma (Hodgkin’s and non- Hodgkin’s) Common in children and young adults Symptoms: Painless slowly growing neck lump Malaise, W t loss, Pallor, Pruritus , Fever, Night sweat 58

59. lymphoma Physical: Site: any cervical lymph node, common in posterior triangle No tenderness Solid and rubbery Smooth, discrete and well defined (not matted) Mobile 59

60. I f the history and physical examination are thorough, the physician should not confuse metastatic malignant cervical tumors with inflammatory lymphadenopathy, cysts, and benign neck tumors. 60

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63. When a patient comes to you with a malignant neck mass…………… 63

64. 1. Step: Detailed History Risk factors: Age Cigarette Alcohol Sun exposure: skin malignancies Previous irradiation: thyroid, salivary glands 64

65. Duration of the mass : infection vs malignancy Pain : infection, tbc Previous malignancy? Concomitant symptoms Otalgia, epistaxis, dysphagia, hoarsness, dyspnea…… 65

66. 2. Step: Physical examination 1. Localization of the mass in the neck Level I masses: Submental area Floor of the mouth Lip tumors Submandibular area Anterior tongue Floor of the mouth Retromolar trigone 66

67. Level II masses: Oral cavity Oropharynx and tonsils Supra- glottic larynx Hypo-pharynx Nasoopharynx 67

68. Level III masses: Larynx Hypopharynx Thyroid Level IV masses: Subglottic larynx Thyroid Cervical esophagus Lung GIT 68

69. Level V masses: Esophagus Lung GIT Nasopharynx Level VI masses Thyroid Subglottic larynx Trachea 69

70. 2. Characteristics of the mass: Hard and fixed Tender Multiple, elastic and mobile 3. Complete head and neck examination Scalp and skin examination. Thyroid examination Salivary gland examination 70

71. 4. ENT examination ( E ye N ipple T hyroid) 71

72. Ear otoscopy and microscopy 72

73. Nasal cavity and nasopharynx: anterior rhinoscopy and 0 degree rigid telescope. 73

74. Oral cavity (mouth floor, tongue, palate, buccal mucosa, gingiva, tonsils, tongue base). Direct inspection and palpation 74

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76. Larynx and hypopharynx: 70 degree rigid telescope . 76

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79. Summary If a patient comes with a tumoral mass in the neck : Try to find the origin of the mass Do not rush to take biopsy And…. 79

80. Take a very good history Do a very careful head and neck examination and Consult the otolaryngologist of a complete ENT examination FNABx Radiologic evaluation (chest x-ray + neck CT) Panendoscopy (otolaryngologist) Excisional biopsy, frozen section, neck dissection. 80