NECK SWELLINGS

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NECK SWELLINGS

• Fourth Year LOCAS teaching
• Eddie Craghill

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Ground Rules

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

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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

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Why do you need to know about neck swellings?

• It's not something that you see everyday so it's
  easy to be out of practice
• There are loads of people out there with some
  kind of neck lump that are brilliant for LOCAS
• You'll look a bit stupid if you get asked by a
  Consultant and don't have a clue what you're
  doing
• MOST IMPORTANTLY....
  Neck lumps didn't really come up last year!

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What gives you neck swellings?

• Thyroid
• Grave's 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
• Pancoast's tumour

• Parotid
• Mumps
• Sarcoid
• Sjogrens
• Neoplasia

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The painful bit.......

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

Sternocleidomastoid
Anterior Triangle
Posterior Triangle
Clavicle
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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
• Pancoast's tumour
• Subclavian aneurysm

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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

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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!!
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Picture Quiz

• BRANCHIAL CYST

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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!
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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.
• DON'T GET CAUGHT OUT
• Can be midline too!

And if it was pulsatile....?
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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 aren't going to want a procession of
  medical students poking someone's carotid artery
  aneurysm all day long so you can forget about it
  for now!

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MIDLINE SWELLING

• 1) THYRO-GLOSSAL
• CYST
• 2) GOITRE

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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
• We'll come back to this one!
• Less common causes
• Lymphadenopathy (I told you...!), dermoid cyst,
  plunging ranula, pharyngeal pouch

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CYSTIC HYGROMA
POSTERIOR TRIANGLE SWELLING
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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 Horner's syndrome to look really slick!
• Subclavian artery aneurysm

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DON'T 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.

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Neck Examination

• LET'S 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? You'll hear lots of
  different things from different people but for
  the purposes of this bit, we're just focusing on
  the neck itself.

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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

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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
• We'll return to goitre in a moment

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Percussion

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

Auscultation
Special Test

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

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THYROIDI told you we'd 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

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Thyroid Anatomy
ARTERIES Superior thyroid artery Inferior
thyroid artery COMMON CAROTID
VEINS Superior thyroid vein Middle
thyroid vein Inferior thyroid vein
INTERNAL JUGULAR
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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
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What's 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

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Picture Quiz 2
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Grave's 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 Grave's
• Associations
• Type 1 DM, pernicious anaemia, Addison's disease

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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

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Hypothyroidism

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

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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
• DeQuervain's thyroiditis ? post-viral
• Riedel's thyroiditis
• Neoplasia

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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

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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
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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

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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

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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

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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

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Can we all go the pub yet?

• Erm.... No

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Salivary Glands

• PAROTID, submandibular and sublingual glands

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What causes parotid swelling?

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

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Parotid tumours

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

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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

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Management

• INVESTIGATION
• ENT examination, CT scan, FNA
• MANAGEMENT
• Parotidectomy, radiotherapy, fascia lata graft
• COMPLICATIONS
• CNVII damage, Frey's syndrome

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Summary

• The location of the swelling is hugely important.
• Take your time over inspection as scars are easy
  to miss when you're pumped full of adrenaline.
• Even it it's 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!

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Tips for Fourth Year

• 1) Don't panic
• 2) Stop ignoring the first rule!
• 3) Have some time off at Christmas so that you
  don't burn out by mid-March.
• 4) Don't underestimate LOCAS but bear in mind
  about 5x as many people fail OSCE as LOCAS.

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Tips for Life

• 1) If you see me out in town, mine's a bitter.
• 2) Don't 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!

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Thanks for listening

• Any Questions?