Initial Assessment of Neck Masses

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Questions and Answers

What is the most common initial assessment for neck masses in children?

Metastatic

Congenital

Inflammatory (correct)

Malignant

What imaging modality is primarily preferred for assessing neck masses?

Magnetic resonance imaging

Computed tomography (correct)

Positron emission tomography

Ultrasonography

Which of the following treatments is suggested for a cystic hygroma?

Sistrunk's procedure

Injection with picibanil (correct)

Control of infection with antibiotics

Surgical excision only

A branchial cleft cyst typically presents as which of the following?

Smooth, fluctuant non-tender mass Signup and view all the answers

What is the characteristic of a thyroglossal cyst?

Elevates on tongue protrusion Signup and view all the answers

Which type of neck mass is commonly known as the most prevalent benign soft tissue neoplasm in the neck?

Lipoma Signup and view all the answers

What differentiates a sebaceous cyst from other neck masses?

It has an adherent punctum Signup and view all the answers

For which situation might an excisional or incisional biopsy be necessary?

For the classification of lymphoma Signup and view all the answers

What is the typical X-ray appearance of an Ameloblastoma?

Honeycomb or fine soap & bubble appearance Signup and view all the answers

What is the recommended treatment for Ameloblastoma?

Excision with a 1 cm safety margin and reconstruction using bone grafts Signup and view all the answers

What distinguishes Osteoclastoma from other jaw tumors?

Requires complete surgical resection Signup and view all the answers

In the case of nodal involvement, what is the recommended surgical intervention?

Unilateral Modified Radical Neck Dissection (MRND) Signup and view all the answers

Which type of epulides is the most common?

Fibrous epulides Signup and view all the answers

Which statement is true regarding Metastasis in lymph nodes?

N3 indicates metastasis in lymph nodes greater than 6 cm Signup and view all the answers

What is the typical clinical presentation of Odontogenic Myxoma?

Multilocular cyst similar to Ameloblastoma Signup and view all the answers

What is a significant characteristic of Alveolar Abscess?

It occurs in the alveolar ridge of the jaw Signup and view all the answers

What is the characteristic feature of tuberculous cervical lymphadenitis?

Cold abscess with normal temperature Signup and view all the answers

Which symptom is associated with a carotid body tumor?

Pulsating lump and transient cerebral ischemia Signup and view all the answers

What indicates the presence of lymphoma in the neck region?

Painless, non-tender and hard masses Signup and view all the answers

What is the primary treatment for Ludwig's angina?

Drainage of pus and antibiotics Signup and view all the answers

What is the primary treatment method for a meatal stone?

Meatotomy and extraction Signup and view all the answers

The boundaries of the parotid region include which of the following?

Inferiorly at the angle of the mandible Signup and view all the answers

Which nerve is critical to avoid injuring during submandibular gland surgery?

Marginal mandibular nerve Signup and view all the answers

Which cranial nerve branch is NOT part of the facial nerve branches that supply the parotid gland?

Vagus Signup and view all the answers

What is a common characteristic of aphthous stomatitis?

It typically heals within 10-14 days. Signup and view all the answers

In which condition is halitosis and regurgitation a common symptom?

Pharyngeal pouch Signup and view all the answers

What is the investigation of choice for a carotid body tumor?

Angiography Signup and view all the answers

What is the appropriate treatment for a ranula that is plunging?

Intraoral excision with drain insertion Signup and view all the answers

Which condition is NOT commonly associated with aphthous stomatitis?

Osteoarthritis Signup and view all the answers

What condition on the tongue is characterized by lesions that do not revert back to normal once the offending agent is stopped?

Leukoplakia Signup and view all the answers

Which surgical technique is appropriate for treating a lingual or sublingual dermoid cyst?

Incision from tip of tongue to frenum Signup and view all the answers

Which of the following cancers is most commonly associated with the tongue?

Squamous Cell Carcinoma (SCC) Signup and view all the answers

What is the primary concern when planning for excision in submandibular gland surgery?

Preserving the facial artery and vein Signup and view all the answers

What is the most characteristic feature of a malignant ulcer on the tongue?

Everted edges Signup and view all the answers

Which treatment is not typically performed for an intraductal stone?

Submandibular sialadenectomy Signup and view all the answers

In what stage of tongue cancer is carcinoma in-situ present?

Tis Signup and view all the answers

What is the primary concern when assessing a primary tumor in tongue cancer at stage Tx?

Primary tumor cannot be assessed Signup and view all the answers

Which type of biopsy is performed for small lesions on the tongue?

Excisional biopsy Signup and view all the answers

Which of the following is a known risk factor associated with tongue cancer?

Oral submucous fibrosis Signup and view all the answers

Where is tongue cancer most commonly found in the oral cavity?

Lateral margin of the anterior two-thirds Signup and view all the answers

Study Notes

Appropriate Initial Assessment of Neck Masses

Pediatric patients are more likely to present with inflammatory, congenital, or malignant neck masses
Young adults have a more diverse range of potential causes, including congenital, inflammatory, and malignant lesions
Individuals over 40 years old are more commonly diagnosed with malignant or inflammatory neck masses

Rule of 80 for Neck Masses

80% of neck masses are neoplastic
80% of neoplastic neck masses are malignant
80% of malignant neck masses are metastatic

Physical Examination

Location of the mass is important for determining the potential source
- Level 1: Lymph nodes, oral cavity, skin
- Level II: Lymph nodes, oropharynx
- Level III: Lymph nodes, larynx, hypopharynx, thyroid
- Level IV: Lymph nodes, thyroid
- Level V: Lymph nodes, nasopharynx

Imaging: Appropriate Use and Interpretation

Ultrasound (US) is a commonly used imaging modality
Computed tomography (CT) is often the preferred imaging technique
Magnetic resonance imaging (MRI) is another option for visualizing neck masses
Positron emission tomography (PET) may be used in certain cases

Cystic Hygroma (Lymphangioma)

It is a congenital lesion, usually presents within the first year of life.
It is located in the posterior triangle of the neck.
The mass is soft, cystic, multilocular, and partially compressible.
The mass is brilliantly trans-illuminant.
Treatment options include injection with picibanil or surgical excision.

Branchial Cleft Cyst

It is a remnant of the second branchial cleft.
Most commonly presents in the second or third decades of life.
Symptoms may include pain, a smooth fluctuant non-tender mass, and a mass located underlying the anterior border of the sternocleidomastoid muscle.
Treatment involves controlling infection with antibiotics followed by surgical excision.

Thyroglossal Cyst

It is a common congenital midline neck mass.
The mass elevates on tongue protrusion.
Treatment involves controlling infection with antibiotics followed by surgical excision (Sistrunk's procedure), which includes removal of the midportion of the body of the hyoid bone.

Lipoma

Lipomas are the most common benign soft tissue neoplasms in the neck.
Diagnosis is typically clinical.

Sebaceous Cyst

The overlying skin is adherent.
A punctum (tiny opening) may be present.
Excisional biopsy is used to confirm the diagnosis.

Cervical Lymphadenopathy

Acute lymphadenitis presents as tender swelling.

Tuberculous (TB) Cervical Lymphadenitis

The upper and middle deep cervical lymph nodes are commonly affected.
The mass is firm, matted, and may fluctuate.
The temperature of the mass is typically normal (cold abscess).
Treatment involves anti-TB drugs for 6-9 months.

Carotid Body Tumor

It is a rare tumor of chemoreceptors.
The tumor is characteristically a pulsating lump.
Symptoms of transient cerebral ischemia may occur.
The tumor is also known as a "potato tumor" due to its hard, non-tender nature.
Angiography is the investigation of choice.
Surgical removal is based on patient factors and symptoms.

Pharyngeal Pouch

It is a diverticulum that forms between the horizontal fibers of the cricopharyngeus muscle below and the lowermost oblique fibers of the inferior constrictor muscle above.
Symptoms include halitosis, food regurgitation, and gurgling sounds.
Treatment involves cricopharyngeal myotomy.

Ludwig's Angina

It is an infection of the floor of the mouth, typically due to dental infections
Treatment includes drainage of pus and antibiotics covering both aerobes and anaerobes.

Lymphoma

It presents as a painless, non-tender, smooth, and discrete lump.
Other symptoms may include weight loss, hepatosplenomegaly, and a mediastinal mass (superior vena caval [SVC] syndrome).
Treatment depends on the stage and is often radiosensitive.

Metastatic Lymph Nodes

Upper cervical lymph nodes are commonly involved in metastases from the upper aero-digestive tract.
The accessory chain of nodes in the posterior triangle may be involved in nasopharyngeal malignancies.
Common sites of occult primary include the tonsil, base of tongue, nasopharynx, and pyriform sinus.
Virchow's node (Troisier's sign) is a metastatic lymph node in the left supraclavicular region, often associated with abdominal or thoracic malignancies.
Metastatic lymph nodes are typically painless, non-tender, and hard masses.

Boundaries of the Parotid Region

Superiorly: Lower border of the zygomatic arch
Anteriorly: Over the masseter muscle
Posteriorly: Curves behind the ear to the mastoid process
Inferiorly: Just below and behind the angle of the mandible

Parotid Duct (Stensen's Duct)

It pierces the buccinator muscle and opens near the second upper molar tooth.

Branches of the Facial Nerve in the Parotid Gland

Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical (supplies the platysma muscle)

Important Relations in the Parotid Gland

Three structures pass through the gland from lateral to medial:
- Facial nerve
- Retromandibular vein (drains into the internal jugular vein - IJV)
- External carotid artery (ECA)

Treatment for Salivary Gland Stones

Meatal stone: Meatotomy and extraction
Intraductal stone: Open the duct at the floor of the mouth, extract the stone, and leave the incision open (performed under local or general anesthesia)
Juxtaglandular stone: Submandibular sialadenectomy
Intraglandular stone: Submandibular sialadenectomy

Submandibular Gland Surgery

Important structures to consider during excision include:
- Facial artery and vein
- Marginal mandibular nerve (MMN) (branch of the facial nerve)
- Lingual and hypoglossal nerves

Marginal Mandibular Nerve (MMN)

To avoid injury to the MMN:
- The incision is made 3-4 cm below the inferior margin of the mandible
- The platysma muscle is incised at this low point

Lingual Nerve

It first lies lateral, then inferior, and then medial to Wharton's duct.

Lesions of the Oral Cavity

Aphthous Stomatitis
- Multiple small, painful ulcers
- Associated with stress or decreased immunity
- Typically heals within 10-14 days
- May be associated with syndromes such as Behcet's or Reiter's syndromes
  - Behcet's Syndrome: Multiple oral ulcers, conjunctivitis, genital lesions
  - Reiter's Syndrome: Multiple oral ulcers, conjunctivitis, urethritis, arthritis, polyarteritis nodosa (PAN)
Ranula
- A bluish translucent cyst of the sublingual salivary gland
- Treatment options include:
  - Excision of the cyst with the gland intra-orally
  - If the ranula is plunging, excision intra-orally with insertion of a drain from the floor of the mouth into the neck cavity
  - Marsupialization may be performed if complete excision is not possible

Lingual and Sublingual Dermoid Cyst

Excision is performed through a vertical incision from the tip of the tongue to the frenum

Hyperkeratosis and Leukoplakia

Hyperkeratosis typically reverts back to normal when the offending agent is stopped
Leukoplakia does not usually revert back to normal and the offending agent is often unknown
Causes include smoking, spices, sepsis, spirits, sharp teeth, syphilis, and candida

Tongue Ulcers

Dental
- Viral: Coxsackie, Herpes
- Bacterial: Acute (Pertussis), Chronic (TB - tip AND syphilis - middle)
- Fungal: Candida
Aphthous
Neoplastic:
- SCC

Incidence and Site of Tongue Cancer

More common in males
Most commonly located on the lateral margin of the anterior two-thirds of the tongue (47%)
Never seen in the midline of the tongue

Etiology of Tongue Cancer

Risk factors:
- 6S + 1C (smoking, spices, sepsis, spirits, sharp teeth, syphilis, candida)
Premalignant lesions: Leukoplakia, erythroplakia, oral submucous fibrosis

Pathology of Tongue Cancer

Microscopically: Squamous cell carcinoma (SCC) is the most common type
Grossly: Ulceration is the most common presentation

Clinical Picture of Tongue Cancer

Malignant ulcers have characteristic everted edges
Other clinical features may include:
- Excessive salivation
- Ankyloglossia (tongue-tied)
- Difficulty articulating speech
- Fetor (foul breath)
- A lump in the neck

Investigations for Tongue Cancer

Biopsy
- Excisional (for small lesions under local anesthesia)
- Incisional (for large lesions)

Classification and Staging of Tongue Cancer

T Stage (Primary Tumor)
- Tx: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in-situ
- T1: Tumor <2 cm in greatest dimension
- T2: Tumor 2-4 cm in greatest dimension
- T3: Tumor 4-6 cm in greatest dimension
- T4: Tumor invades adjacent structures (e.g., mandible, skin)
N Stage (Regional Lymph Nodes)
- Nx: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastases
- N1: Metastasis in a single ipsilateral lymph node <3 cm
- N2a: Metastasis in a single ipsilateral lymph node >3 cm but not >6 cm
- N2b: Metastasis in multiple ipsilateral lymph nodes, none >6 cm
- N2c: Metastasis in bilateral or contralateral lymph nodes, none >6 cm
- N3: Metastasis in any lymph node >6 cm
M Stage (Distant Metastases)
- M0: No evidence of distant metastases
- M1: Evidence of distant metastases

Treatment of Tongue Cancer

Wide local excision with a 2-cm safety margin
If lymph nodes are positive: Unilateral modified radical neck dissection (MRND)
If lymph nodes are negative: Selective supra-omohyoid neck dissection (on the same side as the tumor)
Post-operative radiotherapy (RT) is essential
Reconstruction may be necessary using a radial forearm free flap or pedicled flap (pectoralis major or forehead)

Swellings of the Jaw

Congenital
- Odontomes (developmental abnormalities of the teeth)
  - Ameloblastoma (Adamantinoma)
    - Originates from the dental lamina, most common tumor of the lower jaw
    - Clinical picture:
      - Typically presents in the 4th or 5th decade of life, more common in females
      - Most commonly found in the 3rd molar region, often as a multilocular cyst
      - Locally malignant
    - X-ray: Honeycomb or fine soap and bubble appearance
    - Treatment: Excision with a 1 cm safety margin, reconstruction using bone grafts
      - Incomplete removal can lead to lung metastasis (no lymph node metastasis).
      - It is not radiosensitive (radioresistant)
  - Odontogenic Myxoma
    - Similar to ameloblastoma, but with myxomatous stroma
Traumatic: Mandible fractures
- Most common site: Body of the mandible (29%)
Inflammatory
- Alveolar Abscess: Abscess in the alveolar ridge of the jaw
- Osteomyelitis of the Mandible

Neoplastic

Epulides
- Swellings arising from the muco-periosteum (lumps on the gums)
- Types:
  - Fibrous epulides: Most common type
  - Giant cell epulides: DD from osteoclastoma, located peripherally in the mandible
  - Pregnancy epulides: Caused by elevated estrogen levels during pregnancy and poor oral hygiene
  - Denture-induced granuloma
Osteoclastoma (Giant Cell Tumor):
- A rare locally malignant tumor of the jaw
- Central predilection (arises near the symphysis menti)
- Complete surgical resection is required for adequate treatment as incomplete resection leads to recurrence in about 70% of cases
- It is radiosensitive.

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Description

This quiz focuses on the appropriate initial assessment of neck masses in pediatric and adult patients, highlighting the prevalence of malignant and inflammatory causes. It covers physical examination techniques and imaging modalities utilized for effective diagnosis and management of neck masses.