NECK SWELLINGS

1
NECK SWELLINGS

• Fourth Year LOCAS teaching
• Eddie Craghill

2
Ground Rules

• I WILL ask questions so if I ask you a question
  please answer it! Youll still know more than I
  did this time last year and Im here to tell the
  tale.....
• The best position for avoiding questions is
  usually the second to back row but not
  tonight....
• This isnt exhaustive so you may want to
  supplement your learning from other sources
• Be nice to me as I dont know what Im doing here!

3
Useful Resources

• http//www.entsurgery.net
• Surgical Finals Passing the Clinical
  Kuperberg and Lumley
• Ask Doctor Clarke Surgery for Finals
• MDU Revision Courses Surgery Weekend Revision
  Courses

4
Why do you need to know about neck swellings

• Its not something that you see everyday so its
  easy to be out of practice
• There are loads of people out there with some
  kind of neck lump that are brilliant for LOCAS
• Youll look a bit stupid if you get asked by a
  Consultant and dont have a clue what youre
  doing
• MOST IMPORTANTLY....
  Neck lumps didnt really come up last year!

5
What gives you neck swellings

• Thyroid
• Graves disease
• Multinodular goitre (MNG)
• Toxic MNG
• Thyroiditis
• Neoplasia

• Lymphadenopathy
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Carotid artery aneurysm
• Carotid body tumour
• Laryngocele
• Pharyngeal pouch
• Cystic hygroma
• Pancoasts tumour

• Parotid
• Mumps
• Sarcoid
• Sjogrens
• Neoplasia

6
The painful bit.......

• /-
• Submandibular Triangle
• Submental Traingle
• Carotid Triangle
• Et al

Sternocleidomastoid
Anterior Triangle
Posterior Triangle
Clavicle
7
How do we differentiate neck lumps

• ANATOMICALLY
• ANTERIOR TRIANGLE
• Pulsatile
• Carotid aneurysm
• Tortuous carotid
• Carotid body tumour
• Non-pulsatile
• Lymphadenopathy
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Pharyngeal pouch

THYROID PAROTID

• POSTERIOR TRIANGLE
• Lymphadenopathy
• Cervical rib
• Cystic hygroma
• Pancoasts tumour
• Subclavian aneurysm

8
How do we differentiateneck lumps

• HISTORY
• Systemic symptoms
• Fever wt loss night sweats
• Red flags/ discriminators
• Hoarseness cough SOB
• Background
• In any exam question at Liverpool any African
  person MUST have either TB or HIV!!!
• Age
• Congenital Vs Teens Vs Elderly
• Branchial cyst EBV Neoplasia

9
LYMPHADENOPATHYYour new best friend!

• LOCAL OR GENERALISED
• Local
• Tonsillitis etc.
• Generalised
• Infective
• Infectious mononucleosis (Glandular Fever)
• TB/ HIV
• Toxoplasmosis
• Neoplasia
• Lymphoma CLL
• Ix/ ENT examination CXR USS LN biopsy CT

85 neck swellings!!
10
Picture Quiz

• BRANCHIAL CYST

11
Anterior Triangle Swellings
BRANCHIAL CYST

• Embryological remnant hence in young adults
• Usually within upper 2/3rds of anterior border of
  sternocleidomastoid muscle
• O/E
• soft and fluctuant
• may transilluminate

Fine Needle Aspirate (FNA) usually contains
cholesterol crystals although they can become
infected and produce pus!
12
But if the patient was a bit older....
But if the patient was a bit older....
But if the patient was a bit older....
But if the patient was a bit older....
But if the patient was a bit older....
But if the patient was a bit older....
But if the patient was a bit older....
PHARYNGEAL POUCH

• Pulsion Diverticulum
• Dysphagia size on swallowing
• Usually on the left
• Dx barium swallow Rx by excision of pouch and
  cricopharyngeal myotomy.
• DONT GET CAUGHT OUT
• Can be midline too!

And if it was pulsatile....
13
CAROTID BODY TUMOURS - Glomus tumour/
Chemodectoma

• Not as bad as it sounds! Mortality 9-15
• Benign slow growing tumour of glomus tissue
  (chemoreceptive areas) at carotid bifurcation
• Present in middle age
• PULSATILE hard and elastic
• Classically moves from but not up and
• Dx by angiography and USS Rx by excision
• Examiners arent going to want a procession of
  medical students poking someones carotid artery
  aneurysm all day long so you can forget about it
  for now!

14
MIDLINE SWELLING

• 1) THYRO-GLOSSAL
• CYST
• 2) GOITRE

15
Midline Neck Swellings

• Thyroglossal cyst
• Hard with a clearly defined edge
• Moves up on protrusion of the tongue
• Dx by USS Rx by excision
• Goitre
• Well come back to this one!
• Less common causes
• Lymphadenopathy (I told you...!) dermoid cyst
  plunging ranula pharyngeal pouch

16
CYSTIC HYGROMA
POSTERIOR TRIANGLE SWELLING
17
Posterior Triangle Neck Swellings
CYSTIC HYGROMACavernous lymphangioma

• Lymphatic cysts derived from jugular lymph sac
• Picked up at birth or soon after
• BRILLIANT transillumination!
• Rx by excision although high recurrence rate
• Cervical rib
• Pancoast tumour
• Check for Horners syndrome to look really slick!
• Subclavian artery aneurysm

18
DONT FORGET THESE

• Lipoma
• Soft subcutaneous and fluctuant
• Neurofibroma
• Axillary freckling cafe au lait spots
• Association with acoustic neuroma
• Sebaceous cyst (aka Epidermoid cyst)
• Smooth round and fluctuant. Visible punctum.

19
Neck Examination

• LETS DO SOMETHING PRACTICAL!
• There is always a big debate about what to do
  when an examiner says
• EXAMINE THIS PERSONS NECK
• Does that mean just the neck or peripheral
  thyroid status as well Youll hear lots of
  different things from different people but for
  the purposes of this bit were just focusing on
  the neck itself.

20
INTRODUCTION AND INSPECTION

• Make sure you can see the neck!
• Look from in front and behind
• Scars obvious goitre
• Give them some water to take a sip of whilst you
  observe them swallowing
• Goitre
• Ask them to stick out their tongue
• Thyroglossal cyst

21
PALPATION

• REAL DOCTORS DO IT FROM BEHIND!
• Palpate for lymphadenopathy
• If raised ENT examination for source of
  infection
• - Offer to palpate for other nodes
• I SPED PAST CHIMES
• Fixation and transillumination very important
• Well return to goitre in a moment

22
Percussion

• Find lower border of swelling to ensure that it
  does not impinge trachea
• Listen for bruits
• Pembertons Test

Auscultation
Special Test

• Raise arms above head for 1 minute looking for
• Pink colour
• Stridor

23
THYROIDI told you wed get to it......

• Goitre- usually hypo- hyper- or euthyroid
• EUTHYROID
• You might have a thyroid history rather than exam
  in which case you want to ask about
• Weight loss/ gain
• Appetite
• Sweating and heat intolerance
• Tremor
• Palpitations
• Menorrhagia/ Oligomennorhoea

24
Thyroid Anatomy
ARTERIES Superior thyroid artery Inferior
thyroid artery COMMON CAROTID
VEINS Superior thyroid vein Middle
thyroid vein Inferior thyroid vein
INTERNAL JUGULAR
25
For the purists amongst you....
The thyroid gland is an endocrine gland lying
over the 3rd-4th tracheal rings invested in the
pretracheal fascia of the neck
And these little things behind the thyroid.....
4-6 Parathyroid glands
26
Whats all this goitre business

• GOITRE
• Any enlargement of the thyroid gland. This can
  be diffuse or nodular and can be described with
  respect to its aetiology i.e. physiological
  inflammatory or toxic

27
Picture Quiz 2
28
Graves disease

• Autoimmune disorder
• Immunoglobulins stimulate TSH receptors
• 1) Goitre
• 2) Eye signs
• 3) Hyperthyroidism
• Diffuse goitre with a bruit
• Eye signs almost ALWAYS due to Graves
• Associations
• Type 1 DM pernicious anaemia Addisons disease

29
Multinodular Goitre

• Most common type of goitre in the UK
• Usually euthyroid
• Still important to screen for mass associated
  problems e.g. dyspnoea dysphagia
• If tolerable then can be left alone
• BUT....
• Toxic Multinodular Goitre (TMNG) will look the
  same so hyperthyroidism must be excluded

30
Hypothyroidism

• Usually no goitre except in case of Hashimotos
• Autoimmune condition typically affecting s
• Hyperthyroidism Hypothyroidism
• Firm goitre small-medium sized
• Rx with Thyroxine replacement

31
Otherwise....

• Congenital goitre
• Ectopic thyroid tissue
• Lingual thyroid (thyroid tissue on base of
  tongue)
• Simple goitre
• Iodine deficiency pregnancy puberty
• Inflammatory goitre
• Acute suppurative thyroiditis
• DeQuervains thyroiditis post-viral
• Riedels thyroiditis
• Neoplasia

32
Thyroid Cancers

• MALIGNANT
• 1) Papillary - 70 MF 13
• 2) Follicular - 15 MF 13
• 3) Medullary - 5-10
• 4) Anaplastic - Rare R.I.P.
• BENIGN
• 5) Follicular adenoma
• Plus Lymphoma teratoma squamous and 2er

33
Peripheral Thyroid Status

• On top of the basic exam from before we now have
  some things to add on
• Dry shiny skin
• Skinny/ fat
• Dressed inappropriately for temperature
• Agitated/ Lethargic
• REMEMBER TO GET PATIENT TO SIP WATER AS GOITRE
  WILL MOVE ON SWALLOWING
• WHITE HYPERTHYROIDISM
• ORANGE HYPOTHYROIDISM

Inspection
34
Palpation

• HANDS
• Palmar erythema thyroid acropachy sweaty
• WRIST
• AF large volume pulse
• OUTSTRETCHED ARMS
• Fine tremor
• EYES
• Lid lag opthalmoplegia
• NEURO
• Proximal myopathy slow-relaxing reflexes
• LEGS
• Pre-tibial myxoedema

35
Now you know what it is how do you investigate
it

• BLOODS
• TFTs (T3 T4 and TSG)
• Thyroid autoantibodies
• FBC UEs Ca2 LFTs and ESR
• IMAGING
• CXR USS CT
• SPECIAL TESTS
• FNAC radioisotope scan laryngoscopy

36
And treatment....

• HYPERTHYROIDISM
• MEDICAL Block and Replace
• Carbimazole and
  Thyroxine
• Radioidine
• Takes 2-3/12 to take affect
• Contraindicated in those lt50 years
• Half end up hypothyroid within 10 years
• Propanalol is useful for symptomatic relief
• SURGICAL Sub-total thyroidectomy

37
What else could they ask you

• What are the indications for thyroid surgery
• Cosmetic reasons - Failure of medical Rx
• Non-compliance - Large goitre
• What are the complications of thyroid surgery
• Bleeding/ haematoma formation
• Hypoparathyroidism hypocalcaemia
• Recurrent laryngeal nerve damage hoarseness
• Thryorid crisis
• Hypothyroidism
• Recurrent hyperthyroidism

38
Can we all go the pub yet

• Erm.... No

39
Salivary Glands

• PAROTID submandibular and sublingual glands

40
What causes parotid swelling

• Infection
• Viral
• Mumps
• Bacterial
• Staph 2er dehydration DM alcoholism
• Autoimmune
• Sjogrens syndrome
• Calculi
• Malignancy

41
Parotid tumours

• BENIGN (and most common)
• Pleomorphic adenoma
• If you can only remember one this is it!
• Adenolymphoma (Warthins tumour)
• Check the other side to look slick as 10
  bilateral
• OTHERS
• Mucoepidermoid acinic cell cylindroma
  adenocarcinoma lymphoma metastatic sperad

42
Salivary Gland Examination

• Inspect and palpate as before then
• Visualise inside of the mouth to see
• 1) Submandibular papillae
• - either side of the frenulum
• 2) Parotid duct orifice
• - 2nd upper molar
• IF THERE ARE GLOVES palpate submandibular gland
  bimanually (think mandible claw!) Tenderness
• Test facial nerve
• Perform otoscopy

43
Management

• INVESTIGATION
• ENT examination CT scan FNA
• MANAGEMENT
• Parotidectomy radiotherapy fascia lata graft
• COMPLICATIONS
• CNVII damage Freys syndrome

44
Summary

• The location of the swelling is hugely important.
• Take your time over inspection as scars are easy
  to miss when youre pumped full of adrenaline.
• Even it its screamingly obvious just say it!
• Use as many descriptive words as possible.
• Think laterally! A simple neck exam is very brief
  so they might be wanting you to do something
  else.
• If in doubt lymphadenopathy is a pretty good
  guess!

45
Tips for Fourth Year

• 1) Dont panic
• 2) Stop ignoring the first rule!
• 3) Have some time off at Christmas so that you
  dont burn out by mid-March.
• 4) Dont underestimate LOCAS but bear in mind
  about 5x as many people fail OSCE as LOCAS.

46
Tips for Life

• 1) If you see me out in town mines a bitter.
• 2) Dont volunteer to teach the new fourth years
  in a years time and then leave it until the day
  before to start your presentation!
• 3) Never give too many tips!

47
Thanks for listening

• Any Questions