Personal History

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Fig. 23.4 Lymphatic drainage and cervical LNs

H. Hosny and A. Farag

Middle Chain: which lies around the internal jugular vein and under the sternoclei-

domastoid muscle, dividing this chain of LNs into an anterior group and poste-

rior groups. Also, divided at the level of the hyoid bone “C3” -not by the

Omo-Hyoid muscle- into upper and lower groups. Thus four groups can be

realized:

– Upper Anterior. – Upper posterior. – Lower anterior: DD is the Virchow LNs on the left side which is at the termina-

tion of the Thoracic duct before it drains into the Veins near the conuence of the

Internal Jugular and Subclavian veins. This group of Lymph nodes can be the site

of malignant inltration by retrograde permeation from the thoracic duct after

blockage of its termination by malignant cells which drains the Left Chest cavity

and Lungs and drains the entire abdomen below the diaphragm “Except the bare

area of the Liver which drains into the right thoracic duct through the diaphragm”.

– Lower posterior: the outlying member of this group is the supraclavicular group

on both sides.

– N.B. the Level of the hyoid bone is a water-shed area where Structure below this

area e.g. the thyroid gland drains mainly in the Lower groups of LNs. Involvement

of the upper groups of Lymph nodes occur by retrograde Lymphatic permeation

after extensive metastases in the lower groups of Lymph Nodes. Isolated affec-

tion of the upper group of LNs with malignancy in the presence of a thyroid

malignancy raises the possibility of Lymphoma “Not a metastatic affection from

other types of thyroid Malignancy”.

23 Examination oftheHead andNeck

227

History andClinical Examination

Personal History

Refer to the chapter of general sheath regarding name, age, sex, residence, occupation, marital status and sexual relations and special habits of medical importance.

Special considerations are directed towards the age, sex, sexual relations and special habits as:

Neck masses affecting children are usually benign in contrary to those affecting adults (especially >35y) with higher incidence of malignancy.

Carcinomas are more common in male gender than females.

Malignant tumors are more common in HIV positive patients (risk factor). Also HPV predispose to oro-pharyngeal carcinomas. EPV is associated with lymphomas and nasopharyngeal carcinomas.

Tobacco smoking and Khat chewing predispose to lip, tongue, and oral mucosa and lung carcinomas. Also, alcohol intake increases risk of mouth, oro-nasopharyngeal carcinoma and liver carcinoma.

Complaint

Neck mass is the most frequent presentation. Less frequently, the patient may present with stula, sinus, ulcer, dysphagia (difculty in swallowing), odynophagia (painful swallowing), or localized pain in the neck.

Present History

Analysis of the complaint (s) follows the general principles in the general sheath. Regarding a mass in the neck:

– Onset: Acute onset usually denotes acute inammatory condition (e.g. acute

abscess) or hematoma (following trauma) while gradual onset may be neoplastic.

– Coarse: Progressive coarse especially if rapid over short period of time is a char-

acter of malignancy. In contrary, regressive coarse denote resolving inamma-

tory condition.

– Associated pain denotes inammatory condition e.g. acute lymphadenitis or

acute sialadenitisdue to salivary duct stone (pain associated with mastication).

Malignancy is painless, except late when inltration of a nearby sensory nerve or

adjacent structure occurs.

– Associated lesions in the scalp, face, ipsilateral upper limb, axilla, thorax and

breast should be inquired about.

228

– Local compression manifestations: as dysphagia (compression on the esopha-

gus), dyspnea (compression on the trachea), recent change of voice (inltration

of recurrent laryngeal nerve), ipsilateral otalgia (pain in the ear that may origi-

nate from an ear pathology or referred to it), facial edema (compression on jugu-

lar veins)

– General systemic manifestation of inammation or hyperfunctioning mass e.g.

fever, sweating and malaise. Night fever and sweating suggests TB, intermittent

fever is common with IMN, thyrotoxic manifestations (intolerance to heat, loss

of weight, insomnia, arrhythmias etc.),

– Distant metastasis manifestations especially those to lung, liver, bones and brain

e.g. cough, hemoptysis, jaundice, bony pains or swellings.

H. Hosny and A. Farag

Past andFamily History

– Previous history of neck masses, irradiation or neck surgeries and HPV infection. – Family history of neck masses or tuberculosis. – Inquire about domestic animals, pets and birds (increase risk of toxoplasmosis

and cat scratch disease).

General Examination

(Refer to general sheath.) Abdominal examination is particularly important as supraclavicular lymph nodes enlargement (Virchow’s nodes) may occur due to metastasis from GIT tumors (Troisier’s sign). Also enlargement of the liver or spleen may be found in cases of generalized lymphadenopathy.

Chest examination is also important as apical lung tumors may present in the supraclavicular region.

Local Examination

Inspection

The patient is examined while sitting on a chair in front of the examiner and exposed from head till middle of the chest. This includes:

• Number: Multiple swellings are usually lymph nodes.

• Site: The site oftentimes alludes to the diagnosis. Thorough knowledge of neck

anatomical triangles helps approaching proper diagnosis. For instance, lymph

node enlargement should be considered wherever aggregation of lymphatic tis-

23 Examination oftheHead andNeck

229

sue exists. Dermoid cysts occur in the midline along lines of embryonic closure.

Branchial cyst occurs at the junction of upper 1/3 and lower 2/3 of sternomastoid

muscle partially covered by its anterior border. Thyroid gland enlargement (goi-

ter) occupies lower part of front of the neck in the muscular triangle.

Submandibular gland enlargement occurs at the submandibular triangle below

lower border of the mandible. Lymphatic malformation (formerly known cystic

hygroma) occurs at lateral neck in the posterior triangle.

• Shape: regular shape as rounded, oval, etc. or irregular. Benign masses tend to

have regular shapes while malignant masses are usually irregular.

• Size: better described in centimeters

• Overlying skin: should be inspected for dimpling (suggests attachment of the

mass to it), stulae, sinuses (e.g. single in tuberculous caseating lymph node,

multiple sinuses denote actinomycosis discharging sulphur granules), erythema

due to increased vascularity (e.g. inammation or sarcoma), scars of previous

operation or trauma, and pigmentation (e.g. previous irradiation).

• Surrounding areas: refers to adjacent areas that may be the cause of neck swell-

ing. This includes the scalp (for ulcers or masses), face, nose, ears, lips, mouth

and cheeks including the tongue dorsum and undersurface, oral mucosa, pal-

ate and tonsils (pus from tonsillar crypts). Also the ipsilateral hand, forearm,

arm and axilla should be inspected for ulcers, masses or wounds.

• Special characters:

• Moving up and down with deglutition denotes that the swelling is enclosed within the pretracheal fascia, thus attached to the trachea and/ or the larynx (e.g. thyroid swelling, subhyoid bursa, tuberculous or malignant lymph node attached to the trachea).

• Pulsation if the swelling is related to carotid or subclavian arteries. They are either true (e.g. aneurysm) or transmitted (e.g. lymph node supercial to the artery).

• Impulse on cough (e.g. laryngocele).

Palpation

Includes tenderness, temperature, site, size, shape, surface, skin attachment, edge, consistency, mobility, lymph node assessment and special tests.

• Tenderness: inammatory masses are tender (e.g. acute lymphadenitis, acute abscess). On the other hand, malignant masses are not tender except late when inltration of a nearby nerve or adjacent structure occurs. Tender masses will preclude performing the rest of examination steps as it puts the patient under too much stress and makes it difcult to obtain reliable data. If so, other investigation tools should be done if needed.

• Temperature: swellings with increased vascularity (e.g. inammation, sarcoma) may feel warmer than adjacent areas.

230

H. Hosny and A. Farag

• Site: whether the mass is supercial or deep to related muscles. Swellings deep to a muscle tend to decrease in size while those supercial to a muscle will be more visible. Swellings arising from a muscle do not change their size with muscle contraction.

– Platysma muscle: ask the patient to grimace and see if the mass becomes more

or less visible. (e.g. Lipoma in a subcutaneous plane along the side of the neck will be more visible)

– Sternomastoid muscle: to test a unilateral swelling, ask the patient to turn his

chin to the opposite side against resistance. This will contract one muscle and its relation to that swelling can be identied. To test both muscles, ask the patient to push his chin downwards against resistance.

• Shape: should be described whether regular rounded, oval, …etc. (benign masses usually have regular shapes) or irregular in shape (malignant masses usually have irregular shapes)

• Size: the size is better described in numerical methods (e.g. centimeters) than descriptive methods. In case of irregular shapes, the largest two or three dimensions of the mass are recorded. This makes it easy for follow up of mass progression and for inter-physician communication.

• Surface: benign masses usually have smooth surface, while malignant masses usually have irregular surface.

• Skin attachment: is tested by gliding the skin over the underlying mass or pinching from it. Malignant tumors and tuberculous nodes become xed to the supercial skin and may later ulcerate on the skin or develop a sinus discharging caseous material respectively.

• Edge: is well dened in benign lesions. Lipoma in specic has a characteristic slippery edge. In contrary, malignant and inammatory lesions have illdened edges.

• Consistency: cystic swellings and lipomas feel soft. Benign and inammatory lesions feel rm. Malignant neoplasms and malignant node metastasis feel hard.

• Mobility: Masses arising from longitudinal structures will move across but not along the coarse of that structure (e.g. carotid body tumor, sternomastoid tumors). Also, malignant masses and tuberculous nodes get attached to the surrounding structures e.g. muscles, trachea. So they may show restricted mobility when overlying muscle contracts.

• Lymph nodal status: all accessible neck nodes (external horizontal and vertical groups, tonsils and adenoids) should be evaluated for enlargement and signs of malignancy. They are suspicious of malignancy when they feel hard and get adherent to each other or adjacent structures and overlying skin. The lymph node group enlarged may give clue to primary area affected e.g.:

– Submental nodes point to lesions of the chin, central lips, tongue tip. – Submandibular nodes point to lesions of oor of the mouth, cheeks and tongue. – Upper jugular nodes (jugulodigastric) point to lesion in the tonsils or

nasopharynx.

23 Examination oftheHead andNeck

– Middle jugular nodes (jugulohyoid) point to lesions in the oropharynx, lar-

ynx, esophagus, and thyroid gland.

– Supraclavicular nodes (Virchow’s) point to lesions in the arms, axilla, breast,

chest or the abdomen (Troisier’s sign).

• Special tests:

– Compressibility: either totally compressible as its content is displaced com-

pletely upon pressure (e.g. Venous malformation), or partially compressible when it does not empty completely as its contents move only to a communicating limited space (e.g. lymphatic malformation).

– Fluctuation test: uid lled cysts will show uctuation e.g. Thyroglossal cyst,

Branchial cyst, hyoid bursa and cold abscess. Beware of psuedouctuation that occur with very soft large Lipoma.

– Transillumination: clear uid lled cyst will transilluminate (e.g. lymphatic

malformation), while cysts lled with pus, caseous, proteinaceous, high lipid content or epithelial debris will not transilluminate (e.g. chronic abscess, cold abscess, dermoid cyst, Branchial cyst, Thyroglossal cyst).

– Valsalva’s maneuver: the mass will increase in size with blowing of the nose

while the mouth and nostrils are closed e.g. laryngocele.

Percussion

231

Percussion directly over the manubrium is normally resonant, it may turn dull in huge goiters with retrosternal extension. Direct percussion over a swelling may elicit hyper-resonance in huge laryngocele.

Auscultation

A bruit may be heard over an aneurysm due to turbulence of blood ow or upper pole of thyroid gland in 1ry thyrotoxicosis due to increased vascularity.

Differential Diagnosis ofNeck Masses (Table23.1)

The etiology of neck masses can be generally be attributed to congenital, inammatory and neoplastic causes. Although they are common presentation at all ages, the etiology of neck masses in children varies from those in adults. Most of neck masses in children are benign while those occurring in adults have a higher incidence of malignancy and should be considered malignant until proved otherwise.

232

Table 23.1 Common neck swellings according to site

Benign Malignant

Central masses

Lateral masses

Ranula Thyroglossal cyst Thyroid adenoma, MNG Subcutaneous mesenchymal tumors e.g. Lipoma, broma

Lymphadenitis Granulomatous diseases e.g. TB, sarcoidosis Branchial cyst Sialadenitis Neurobroma, neuroma Paraganglioma Vascular malformations

H. Hosny and A. Farag

Thyroid carcinoma Metastatic carcinoma to lymph nodes Lymphomas

Metastatic carcinoma Lymphomas Salivary gland tumors Sarcomas Malignant Fibrous histiocytoma

Congenital Anomalies

Vascular Origin

• Haemangioma: starts after birth, have three phases; progressive, stationary and nally regressive phases. 50% will disappear completely by 5years.

• High ow vascular malformations e.g. arterial malformation and arteriovenous stula

• Low ow vascular malformations e.g. venous malformations and lymphatic malformations

Non Vascular Origin

• Thyroglossal cyst: occurs in the midline in relation to the hyoid bone due to failure of complete closure of tract along which the thyroid gland descends from base of the tongue to its normal anatomic location in the neck. It moves up with protrusion of the tongue. Sudden enlargement may occur if infected and form an abscess. It may harbor thyroid tissue thus malignancy can occur.

• Branchial cyst: due to incomplete fusion of the 2nd brachial arch (95%) with the 5th arch. It presents as a cystic swelling in the lateral neck at the junction of upper 1/3 and lower 2/3 of sternomastoid muscle anterior border, lateral to internal carotid artery. It may grow rapidly in size if infected as its wall is rich in lymphatic tissue. It commonly presents in children but may present late.

• Ranula: is a retention cyst (Mucocele) due to obstruction of a sublingual salivary gland. It is usually asymptomatic found at one side of the midline at the upper neck. If large, it may interfere with swallowing or speech. When it occurs deep to mylohyoid muscle (plunging Ranula) it can be felt through the oor of the mouth.

23 Examination oftheHead andNeck

• Teratomas: constitutes germ cell tumors containing all germ cell layers. Thus may contain fat, cysts, calcication and epithelial debris. They present as rapidly expanding neck mass that require rapid intubation. It may be associated with other anomalies e.g. cleft lip palate, heart anomalies, trisomy 13 or trisomy21.

• Dermoid cyst: contains only 2 germ cell layers (ectoderm and mesoderm). It occurs at the midline along lines of embryonic fusion.

233

Inammatory andInfectious Lesions

• Acute lymphadenitis: is the most frequently encountered neck swelling as the neck is rich in lymphatic tissues that drain the scalp, face and upper aero- digestive tracts. They present as multiple tender mobile swellings in anatomical sites of lymph nodes. Symptoms of the primary lesion are usually present e.g. rhinorrhea, dysphagia, odynophagia, otalgia...etc. If necrosis within the lymph node occurs an abscess will develop and uctuation can be elicited. Common organisms are bacteria (staphylococci and streptococci) and viruses (HPV; predisposes to oropharyngeal squamous cell carcinoma, and EPV predisposes to nasopharyngeal carcinoma).

• Salivary gland sialadenitis: presents with pain associated with mastication due to obstruction of a major salivary duct by a stone or decreased ow in cases of severe dehydration (especially in elderly). Note that carcinoma at oor of the mouth may compress and obstruct Wharton’s duct and cause symptoms similar to stone obstruction.

• Granulomatous diseases: e.g. tuberculosis, sarcoidosis, cat scratch disease, Kawasaki disease. Other systemic manifestations are usually present and point to the disease.

Neoplasms

A. Metastatic lymph node disease from regional primary focus (in the head), dis-

tant primary focus (skin or viscera) or local primary in the neck (e.g. thyroid and salivary glands). They present as hard immobile nodes yet can be counted.

B. Primary lymph node disease e.g. Hodgkin and non-Hodgkin lymphomas.

Systemic manifestations are usually present and many lymph node groups can

be present at time of presentation. C. Thyroid gland neoplasms present as anterior or lateral neck swellings. D. Salivary gland tumors 80% of parotid gland tumors are benign, the common-

est being pleomorphic adenoma. 50% of submandibular salivary gland tumors

are malignant. The commonest malignant salivary gland tumor is mucoepider-

moid carcinoma. Submandibular salivary gland mass cannot be rolled over the

mandible while, a lymph node can be rolled over it.

234

H. Hosny and A. Farag

E. Neurogenic neoplasms

– Schwannoma: arise from cranial, spinal nerves or sympathetic chain. In

adults, usually found in parapharyngeal space.

– Neurobroma: skin or subcutaneous nodule (s), may be associated with

brownish pigmentation of the skin (café au lait patches).

– Tumors of neuroblastic origin e.g. neuroblastoma and ganglion

neuroblastoma.

– Neuroma occurs from nerve injury during surgery or following trauma e.g.

great auricular nerve injury during parotidectomy. Patient presents with small tender nodule with paraesthesia.

– Paraganglioma “carotid body tumor”: it is neural crest in origin, arises in the

carotid body and typically splays the internal and external carotids. It may secret catecholamines and leads to uncontrolled hypertension and needs special attention during surgical excision.

F. Metastatic carcinoma with unknown primary is a squamous cell carcinoma

in 90% of the cases. Others include adenocarcinoma and melanoma. They need

careful attention to hidden sites e.g. tonsils, nasopharynx, pyriform fossa and

impalpable submucosal tumors.

Chapter 24

Examination ofaMass intheHead andFace

AhmedFarag, AmrKamelElfeky, andNicholasJohnson

Abstract Personal History: In the Pathology—Epidemiology section i.e. which

type of patient can have this complaint. It should be interpreted after the complaint as a rst Time-Out. Complaint: Swelling: painful or Painless. Ulcer or ulcerating mass. Site is the most important Item in interpreting the complaint.

Keywords Head · Face · Area · Parotid · Forehead · Scalp · Lymph · Node · Mass · Ulcer