Anatomy and Diseases of the Neck

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					ENT                                    Anatomy and Diseases of the Neck                                   Page 1 of 4

Neck Diseases                                                          -   Other Structures
   • Mass in the neck -very common clinical finding                            • Trapezius muscle- posterior
   • Often the result of inflammation (resolves in                                 border of neck
                                                                               • Carotid bulb or bifurcation
   • Maybe serious-malignant tumors
   • Warning signs and symptoms of a dangerous                         -   Location of an abnormal neck mass-
       disorder - important                                                predictive value
                                                                       -   Cervical lymphatics divided - six anatomic
Anatomy of the Neck                                                        regions
   • Complex and intricate structure
   • Location of major neck structures and the
      distribution of lymph nodes in the neck –
   • Normal Vs Abnormal

                                                             •   Zone I - submandibular and submental nodes.
                                                             •   Zones II through IV- lymph nodes along the
                                                                 jugular vein region deep to the
                                                                 sternocleidomastoid muscle in the upper, mid,
                                                                 and lower neck.
                                                             •   Zone V- nodes that lie posterior to the
                                                                 sternocleidomastoid muscle
                                                                     • commonly enlarged with viral
                                                                          infections , TB
                                                                     • site of metastasis - NPCA.
                                                             •   Zone VI-between the carotid sheaths bilaterally,
                                                                 prelaryngeal and pretracheal nodes that drain the
                                                                 larynx and thyroid gland

                                                         Diagnostic Evaluation

                                                             •   Understanding of what represents abnormality in
                                                                 cervical lymph nodes- Important
                                                             •   Enlargement from inflammatory disorders usually
                                                                 resolves within 2 weeks
                                                             •   Any distinct mass in the parotid gland or thyroid
                                                                 gland is abnormal and should be evaluated

                                                         Normal versus abnormal findings in cervical lymph node

                                                         Characteristic        Normal         Abnormal
                                                         Size                  <1 cm          >1.5 cm
   –   Several normal structures are palpable on neck
                                                         Mobility              Movable        Decreased or
          - Parotid gland
                                                         Consistency           Soft, fleshy   Firm, rubbery,
          - Mastoid tip
                                                                                              or matted
          - Transverse process of the C1 vertebra
                                                         Presence of mass?
          - Submandibular glands.
                                                         Parotid gland     No                 Yes
          - Sternocleidomastoid muscle
                                                         Thyroid gland     No                 Yes
          - Laryngeal structures:
                  • hyoid bone, thyroid, cartilage,
                       cricothyroid, membrane, cricoid
                                                         Findings that increase likelihood of malignant disease in
                       cartilage, trachea
                                                         patient with neck mass
          - Thyroid gland
ENT                                      Anatomy and Diseases of the Neck                                 Page 2 of 4

Demographic characteristics and history                         ― Oral lesions, recent trauma, dental problems,
Age >40 yr                                                        voice change, breathing difficulties, odynophagia,
Previous head and neck squamous cell carcinoma                    dysphagia, globus sensation, hemoptysis, referred
Heavy tobacco use                                                 ear pain, muffled or decreased hearing, and
Heavy alcohol consumption                                         constitutional symptoms (eg, fever, night sweats,
Drug use (eg, marijuana)                                          anorexia, weight loss)
Family history of cancer                                        ― Previous radiation exposure- related to thyroid CA
Previous radiation therapy (eg, for thymic disease, acne)
Mass present >2-3 wk                                        Physical examination
                                                               • Mass is a lymph node or part of another neck
Symptoms and system findings                                        structure
Absence of recent associated upper respiratory tract           • Determined by-location and characteristics on
disease                                                             palpation.
Voice change (eg, hoarse, muffled)                             • Size, consistency, tenderness, and mobility of the
Shortness of breath (stridor)                                       mass should provide diagnostic clues
Odynophagia                                                    ― Acute inflammatory masses tend to be soft,
Dysphagia                                                           tender, and mobile
Globus sensation                                               ― Congenital masses may be tender if infected but
Hemoptysis                                                          are generally soft, smooth, nontender, and
Referred ear pain (otalgia)                                         mobile
Hearing loss (unilateral)                                      ― Chronic inflammatory masses and lymphomas are
Weight loss                                                         often nontender and rubbery and may be either
Cough                                                               mobile or feel like matted nodes
Difficulty handling secretions                                 ― Vascular masses may be pulsatile or have an
Chronic unilateral nasal discharge or bleeding                      associated bruit on auscultation
                                                               ― Malignant neoplasms tend to be very firm or hard
Physical examination findings                                       and nontender, and they undergo progressive
Characteristics of abnormal lymph node                              enlargement.
Ulcer or lesion in oral cavity or pharynx
Facial paralysis                                            Differential diagnosis
Unilateral serous otitis media without upper respiratory
tract infection                                             Normal neck structures that may be palpable
Normal results on ear examination in presence of otalgia           Transverse process of C1 vertebra
Presence of very firm mass                                         Hyoid bone
Unilateral nasal obstruction                                       Thyroid and cricoid cartilage
Induration in mouth                                                Atherosclerotic carotid bulb

History taking                                              Inflammatory and infectious conditions
    • Thorough and accurate clinical history -              Cervical lymphadenitis
        differential diagnosis                              Bacterial
    • Duration of symptoms -most important historical       Beta-hemolytic streptococci, Staphylococcus aureus
        points                                              Unusual disorders: cat-scratch disease, actinomyces
    • Inflammatory disorders-acute in onset ,resolve                infection, tularemia
        within several weeks,associated with recent         Cutaneous infection of scalp or face
        upper respiratory tract infection.                  Mycobacterial tuberculosis, atypical mycobacterial
    • Congenital masses- present for an extended                    infection
        duration, sometimes since birth, enlarges rapidly
        after a mild upper respiratory tract infection      Inflammatory and infectious conditions:
                                                                 – Viral
    • Malignancy/ metastatic carcinoma-                            – Epstein-Barr virus infection
    ― History of progressive enlargement                           – HIV infection
    ― Sudden appearance of a neck mass that has                    – Herpes simplex virus infection
      actually been present for a long time and has                – Cytomegalovirus infection
      been enlarging progressively                               • Parasitic (toxoplasmosis)
    ― Persistent neck mass in an adult                           • Fungal (coccidioidomycosis)
    ― Metastatic squamous cell carcinoma originating in          • Sialadenitis (including parotid, submandibular,
      the upper aerodigestive tract- most common                   sublingual glands)
      cause of malignant tumors                                  • Obstructive (stone)
    ― > 80% - associated with tobacco and alcohol use            • Bacterial
      in persons over 40 years of age                            • Viral (mumps)
                                                                 • Thyroiditis (acute, subacute, or chronic)
    ― Additional important signs and symptoms :                  • Other inflammatory condition
ENT                                      Anatomy and Diseases of the Neck                                 Page 3 of 4

    •   Neck abscess                                       –   Viral and bacterial pharyngitis - acutely swollen and
                                                               tender lymph nodes, which usually return to normal
Congenital disorders                                           in several weeks.
   • Thyroglossal duct cyst                                –   Group A beta-hemolytic streptococcus -most common
   • Branchial cleft cyst or fistula                           cause of bacterial pharyngitis
   • Dermoid cyst                                          –   Throat cultures or antigen-detection (rapid strep)
   • Lymphangioma                                              tests- clinical picture is atypical or unclear
   • Congenital torticollis (rare)
   • Teratoma (rare)                                       Cervical lymphadenitis - seen in all age-groups
   • Thymic mass (rare)                                    – most common in children and adolescents.
                                                           – Viral and bacterial pharyngitis - acutely swollen and
Neoplastic disorders                                           tender lymph nodes, which usually return to normal
Benign                                                         in several weeks.
   • Mesenchymal tumor                                     – Group A beta-hemolytic streptococcus -most
   • Lipoma                                                    common cause of bacterial pharyngitis
   • Fibroma                                               – Throat cultures or antigen-detection (rapid strep)
   • Neural tumor                                              tests- clinical picture is atypical or unclear
   • Salivary gland (including parotid, submandibular,
       sublingual, minor salivary glands) mass             Infectious Mononucleosis- enlarged nodes in the
   • Thyroid mass                                          posterior triangle of the neck (zone V)
   • Vascular disorders                                    – Heterophil antibodies
   • Paraganglioma (glomus vagale, carotid body
       tumor)                                              *Mycobacterial infections - chronic in nature.
   • Vascular malformation (hemangioma,                    – common in adults and usually presents with
       arteriovenous malformation, aneurysm,                  pulmonary findings, rubbery and matted lymph
       lymphangioma)                                          nodes, and occasional violaceous changes in the skin
Malignant                                                     overlying the nodes.
   • Primary neck tumor
   • Sarcoma or soft-tissue tumor                          *Atypical tuberculosis -common in children , most often
   • Salivary gland tumor                                  presents without pulmonary symptoms, nontender mass
   • Thyroid tumor                                         in the submandibular area, usually with a weakly positive
   • Parathyroid carcinoma                                 or negative tuberculin skin test
Metastasis from supraclavicular primary tumor              Epidemic parotitis (mumps), Acute sialadenitis -caused
   • Head and neck squamous cell carcinoma                 by a stone obstructing either the parotid or
   • Cutaneous squamous cell carcinoma                     submandibular duct can result in a tender, inflamed,
   • Melanoma                                              swollen gland.
   • Metastasis from thyroid or salivary gland tumor       *Acute suppurative sialadenitis- debilitated elderly
Metastasis from infraclavicular primary tumor              patients with dehydration
   • Lung cancer                                           – Finding of purulent drainage from the inflamed duct
   • Esophageal cancer                                         when it is massaged.
                                                           – Hydration and use of antistaphylococcal antibiotics,
Neck mass in Children                                          warm compresses, and sialagogues (eg, lemon
   The vast majority of children presenting with a "neck       wedges) usually relieve suppurative sialadenitis
   mass" are found to have cervical adenitis. Of those
   with an actual isolated mass, about 80% have a          Thyroiditis -anterior neck swelling and tenderness of
   benign cause , most often inflammatory or congenital.   varying severity, depending on the type and chronicity of
   When malignant neoplasms occur in children, they        the process.
   are usually lymphomas and soft-tissue sarcomas.
                                                           Subsequent evaluation
Neck mass in Adults                                           • Tailored to the clinical impressions obtained from
   in adults over 40 years of age, 80% of solitary neck           history taking and physical examination.
   masses are caused by a malignant neoplasm . The            • Rapid strep tests or cultures for strep
   great majority are metastatic squamous cell                • Serum testing for antibodies to viral infections,
   carcinoma from a primary tumor located above the               including mumps and Epstein-Barr virus
   clavicles.                                                 • Skin testing for tuberculosis and fungal infections
                                                                  and serum testing for HIV infection
Inflammatory and infectious masses                         Congenital masses
Cervical lymphadenitis - seen in all age-groups               • Thyroglossal duct cyst- most common
– most common in children and adolescents.                 – Presents as a midline or near-midline mass that
                                                              usually elevates on swallowing or on protruding the
ENT                                       Anatomy and Diseases of the Neck                                      Page 4 of 4

–    This characteristic differentiates it from a dermoid     cultures, depending on the probability of infection
    cyst, which often presents in a similar location.         determined in differential diagnosis.
    • Branchial cleft cyst
–   smooth mass underlying the sternocleidomastoid                • Incisional or excisional biopsy
    muscle and often seems to appear rapidly after an            -Adults-rarely indicated for diagnosis of neck masses in
    upper respiratory tract infection                         adults but is often necessary for classification of
    • Lymphangioma                                            lymphomas
–   Less common and rarely presents at birth but                 -Children- incisional or, preferably, excisional biopsy is
    develops during the first several months of infancy.      indicated in lieu of fine-needle aspiration
–   Soft, diffuse swelling and can often be                        Endoscopy- search for primary
    transilluminated                                               CT scan and /or Magnetic Resonance Imaging
    • Thymic masses protruding into the chest,                     Ultrasound
        teratomas, and congenital torticollis- rare
                                                              Indications that patient with neck mass should be
Neoplasms                                                     referred to subspecialist
Benign                                                            • Mass does not resolve with 2-wk course of
    • Lipoma -most common benign soft-tissue tumor                    antibiotic therapy
        in the neck,soft consistency and chronicity usually       • Malignant tumor is suspected
        allow diagnosis by clinical examination alone             • Mass is enlarging rapidly (especially in absence of
    • Salivary glands mass- always abnormal and must                  inflammation)
        be investigated                                           • Mass is in thyroid gland
Distinguishing chronic inflammatory changes from                  • Mass is in parotid gland
neoplastic processes is difficult                                 • Mass is fixed
    • Parotid gland- 80% benign, the most common                  • Cervical lymph nodes are matted
        benign tumor being pleomorphic adenoma
        (benign mixed tumor). (The most common
        malignant tumor in the parotid gland is
        mucoepidermoid carcinoma.)
    • Submandibular gland- 50% benign, with the most
        common malignancy being adenoid cystic
    • Thyroid nodules - common
    • Inflammatory conditions, benign neoplasms, and
        malignant tumors - coexist within the thyroid
        gland, and malignant conditions in the presence
        of a goitrous process or chronic inflammatory
        disorder (eg, Hashimoto's disease) can complicate
        decision making.
    • Goiters- common, especially in iodine-deficient
        geographic areas, manifest as diffuse
        enlargement, often asymmetric, of the thyroid
        gland and may have diffuse nodularity.
    • Conservative Vs Surgery

   • Primary -arise from any of the tissue components
       in the neck ( thyroid gland, salivary glands, and
       lymphoid tissue)
   • Metastatic- Most cancerous neck masses in the
       low neck (zone IV or lower zone V) originate in
       primary cancers below the clavicle (eg, lung,
   • Metastatic lymph node masses in the mid or
       upper neck- most common squamous cell
       carcinoma arising from the aerodigestive tract
   • Need -search for the primary cancer.

Subsequent evaluation
    • Fine-needle aspiration
   -Cells are sent for cytologic examination but may also
be prepared for bacterial, fungal, and tuberculosis

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