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

1. Physical examination of the
neck
Elias jan arteen
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13. Lymphatic drainage
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16. Levels (zones) of lymph nodes
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17. Neck examination
1. Inspection
2. Palpation
- lymph nodes
- salivary glands
- thyroid gland
- larynx and trachea
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18. Neck masses
Inflammatory
Congenital
Traumatic
Neoplastic
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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
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21. Lymphadenitis
Deep neck infections:
- Ledwing angina
- peri tonsillar abscess
- Para pharyngeal abscess
- Retropharyngeal abscess
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22. Congenital neck masses
• Branchial cleft cysts
• Thyroglossal cyst
• Vascular: Haemangioma and
lymphangioma
• Dermoid cysts
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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
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26. Malignant neck tumors
Lymphoma
Thyroid carcinoma
Salivary glands malignancies
Metastatic lymph nodes
Vascular
Neurogenic
Soft tissue tumors
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27. Benign neck tumors
Lipoma
Carotid body tumor
Cystic hygroma
Pharyngeal pouch
Sternomastoid tumor
Cervical rib
Salivary glands benign tumors
Thyroid benign tumors
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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
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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.
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31. Ranula
 Cystic swelling floor
of mouth(ranula little
frog)
 Mucus extravasations
from sublingual
salivary gland
 May extend through
FOM muscles into
neck “plunging
ranula”
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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
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33. Carotid body tumor
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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
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36. Cystic hygroma
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37. Cystic hygroma
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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
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41. Zenker diverticulum
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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)
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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
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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)
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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
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47. Cervical rib
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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
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53. Thyroid gland
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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
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55. Head and neck cancers
6th 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
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57. 2. Metastatic lymph nodes
(Enlarged lymph node- Asymmetric- Adult)
Remember
Primary cervical malignancy is rare and
almost all malignant cervical tumors
except for lymphomas are metastatic
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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, Wt loss, Pallor, Pruritus , Fever,
Night sweat
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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
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60. If the history and physical
examination are thorough, the
physician should not confuse
metastatic malignant cervical
tumors with inflammatory
lymphadenopathy, cysts, and
benign neck tumors.
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63. When a patient comes
to you with a
malignant neck
mass……………
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64. 1. Step: Detailed History
• Risk factors:
Age
Cigarette
Alcohol
Sun exposure: skin malignancies
Previous irradiation: thyroid, salivary
glands
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65. Duration of the mass: infection
vs malignancy
Pain: infection, tbc
Previous malignancy?
Concomitant symptoms
Otalgia, epistaxis, dysphagia,
hoarsness, dyspnea……
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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
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67. Level II masses:
Oral cavity
Oropharynx and tonsils
Supra-glottic larynx
Hypo-pharynx
Nasoopharynx
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68. Level III masses:
Larynx
Hypopharynx
Thyroid
Level IV masses:
Subglottic larynx
Thyroid
Cervical esophagus
Lung
GIT
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69. Level V masses:
Esophagus
Lung
GIT
Nasopharynx
Level VI masses
Thyroid
Subglottic larynx
Trachea
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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
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71. Ear otoscopy and
microscopy
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72. • Nasal cavity and
nasopharynx:
anterior rhinoscopy
and 0 degree rigid
telescope.
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73. Oral cavity (mouth floor, tongue, palate, buccal
mucosa, gingiva, tonsils, tongue base). Direct
inspection and palpation
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75. Larynx and hypopharynx: 70 degree rigid
telescope.
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78. 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….
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79. 1. Take a very good history
2. Do a very careful head and neck
examination and Consult the
otolaryngologist of a complete ENT
examination
3. FNABx
4. Radiologic evaluation (chest x-ray +
neck CT)
5. Panendoscopy (otolaryngologist)
6. Excisional biopsy, frozen section,
neck dissection.
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80. Pearls
Avoid excisional biopsies
Use CT but consider MRI for
salivary gland problems
Role of nonionizing ultrasound
Like a stethoscope?
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