Neck Mass Work Up

NECK MASS—-DANIEL TODD, MD
Hx: AGE, DURATION, RAPIDITY OF GROWTH, ASSOC Sx-PAIN-FLUCTUATION OF SIZE & Sx-CHANGES WITH EATING, ABILITY TO SWALLOW AND BREATH, PMHx, SMOKING, EXPOSURE TO CATS/CAT FECES-TB-HIV, TRAVEL, DENTALWORK OR INFXN, RAW MEAT INGESTION, SCALP LESIONS (HX OF SCALP LESION EXCISED) OR INFXN, HS MEGALLY (GLYCOGEN OR LIPID STORAGE DISEASES), FEVER-NIGHT SWEATS-COUGH, Fhx (MEN SYNDROMES), CONG SYNDROMES
AGE:
NEONATE: S.a, GBS
INFANT: Sa, GBS, KAWASAKI
1-4: Sa, GABHS, ATYPICAL MYCOBACTERIUM
5-15: ANAEROBIC BACTERIA, TOXO, CAT SCRATCH, MB
YOUNGER THAN 15—MORE LIKELY CONGENITAL
OLDER THAN 35-40 DIF DX IS CANCER, CANCER, CANCER
PE: COMPLETE H & N EXAM—PAY SPECIAL ATTN THE THE SCALP—ALWAYS TURN THE EYELID
LOCATION CAN BE HELPFUL—MASTOID NODE = POST AURICULAR LN, NODES OF KRAUSE=JUGULAR FORAMEN LN’S–VERNET’S JUGULAR FORAMEN SYNDROME, TONSILLAR (PRINCIPLE NODE OF KUTTNER) JUGULODIGASTRIC LN, VIRCHOW’S NODE=SUPRACLAVICULAR LN (WHERE THE LEFT THORACIC DUCT EMPTIES INTO THE LEFT SUBCLAVIAN VEIN)—MASS OR CYST LOW IN THE NECK—-THYMIC CYST, LYMPHANGIOMA, THORACIC DUCT CYST, METASTASIS(MOST LIKELY GI), NODE OF ROUVIER= THE LATERAL MOST RETROPHARYNGEAL LN (GLANDS OF HENLE=RP LYMPH NODES—BEGIN TO ATROPHY AT AGE 4), TRIPLE OR TAILEN’S CHAIN = INT. JUGULAR VEIN, DELPHIAN LN OVER CRICOTHYROID MEMBRANE
NOTE SIZE, SHAPE, MOBILITY (VERTICAL AND HORIZONTAL PLAY—ASSOC WITH CAROTID SHEATH), FIXATION, PULSATION/THRILL/BRUIT—MUST AUSCULTATE, FLUCTUANCE, LOCAL TEMP GRADIENTS, COLOR, TRANSILLUMINATION, OVERLYING SKIN CHANGES, COMPRESSIBILITY
LAB:
CBC WITH PBS
ESR
HIV—-HIV ASSOC. LAD DEMONSTRATE 95% FOLLICULAR HYPERPLASIA
CMV IGM, EBV IGM, TOXO IGM, BARTONELLA IGM, ASO TITIERS
PPD AND CXR
THROAT CULTURE
THYROID PROFILE, TN99 SCAN
MONO SPOT
CMV, EBV, TOXO, TULAREMIA, ROCHILEMEA HENSII, AFEFIA FELIS, MHATP, HISTO
ANTI- DNAse B TITER
FEBRILE AGGLUTININS : (BRUCCELOSIS ABORTUS, FRANCESCELLA TULARENSIS)
CAT SCRATCH Ab (OKLAHOMA CHILDRENS)
PPD
FNA—EMLA–20 GUAGE NEEDLE—GS,-AFB STAINS, AND ANAEROBIC, AEROBIC, FUNGAL, AND MYCOBACTERIAL——–CERTAINLY MAY REPEAT FNA (DO WITH US OR CT GUIDANCE) CULTURES—PCR FOR NTM
CXR—(SARCOID/TB)
LAT SOFT TISSUE—MAY GIVE CLUES TO RP ABSCESS
CT OF NECK–WITH AND WITHOUT CONTRAST
MRI
DUPLEX–LEMIER’S
OPEN Bx—BE SURE TO TAKE ADVANTAGE OF ANESTHESIA AND GET LP AND BM Bx CONCOMMITANTLY
I&D GS, C&S AEROBIC, ANAEROBIC, ACID FAST STAINS AND CULTURES, FUNGAL STAINS AND CULTURES
DIFF Dx:
INFLAMMATORY/INFXOUS: MOST COMMON—PRIMARILY VIRAL & BILAT—TRIAL OF ABX AND DRAG YOUR FEET
MONONUCLEOSIS—CAN BE UNILAT (EBV, CMV, TOXO)
INFXN (STAPH OR GABHS)
ATYPICAL MTB—-CHILDREN AND IMMUNOCOMPROMISED,SUBMANDIBULAR TRIANGLE—PAROTID IS COMMON, USUALLY UNILAT AND SINGLE LYMPH NODE, NL CXR, MARGINAL PPD, OFTEN NO HX OF EXPOSURE, NO CONST. SYMPTOMS
MTB—-OLDER, BILAT –MULT –LAD, SUPRACLAV (POST TRIANGLE, + HX EXPOSURE, +PPD, +CXR
CAT SCRATCH
TULAREMIA
TOXO
LYME Dz
INFECTED BRANCHIAL CLEFT CYST
DIVIDED INTO LYMPHOID, GRANULOMATOUS, INFLAMMATION OF NON LYMPHOID TISSUE, AND ABSCESS
CONGENITAL/DEVELOPMENTAL:
MOST CONG NECK MASSES APPEAR IN THE 1ST 2 DECADES OF LIFE
EXCLUDING MIDLINE NECK MASSES—-BRANCHIAL CLEFT CYSTS ARE THE MOST COMMON CONG LESION OF THE ANT TRIANGLE—ANT TO SCM—SECOND IS MOST COMMON—TONSIL—BETWEEN ICA AND ECA—-ALWAYS OVER 12
MALIGNANT DEGENERATION IS RARE
MIDLINE
THYROGLOSSAL DUCT CYST (TGDC)—-FORAMEN CECUM
MIDLINE CERVICAL DEFECT
DELPHIAN LN—–MIDLINE—THYROID OR LARYNGEAL CA
POST TRIANGLE—LYMPHANGIOMA/LYMPHOHYPERPLASIA—–TRY TO TRANSILLUMINATE
THINK OF NPCA, THYROID CA, OTHER SCCA VS MTB OR MONONUCLEOSUS
EPITHELIAL (CUTANEOUS) CYSTS
EPIDERMAL INCLUSION CYSTS=SEBACEOUS CYSTS=EPIDERMOID CYST=EPIDERMAL CYST

PILAR OR TRICHILEMMAL CYST
STRATOCYSTOMA MULTIPLEX
TERATOMAS
4 TYPES
DERMOID CYST—REALLY A BENIGN FORM OF MATURE TERATOMA
TERATOID CYST
—CROSSES THE DISTINCTION FROM CYST(MALFORMATION) TO NEOPLASM—-
TERATOMA—–USUALLY SOLID, ALL 3 GERM LAYERS
HAIRY POLYP
EPIGNATHUS “ON THE JAW”–WELL DIFF EXOPHYTIC MASS OF THE OC OR PHARYNX—OFTEN WITH WHOLE ORGANS–OFTEN FATAL DUE TO AIRWAY PROBLEMS
NEOPLASTIC:
THYROID TUMORS ARE ALL ENDODERMAL (POUCH) DERIVATIVES EXCEPT MEDULLARY (NEURAL CREST DERIVATIVES/ECTODERMAL) PARAFOLLICULAR C-CELLS FROM THE ULTIMOBRANCHIAL BODY—THYROID METS FOLLOW THE INF THYROID ARTERY—TO BRACHIOCEPHALIC TRUNK—LEAD TO POST TRIANGLE /SUPRACLAVICULAR LAD
DELPHIAN LN—–MIDLINE—THYROID OR LARYNGEAL CA
CYSTIC MASSES CAN BE CA—SCCA ARISING FROM WALDEYER’S RING OR PAPILLARY THYROID CA—OFTEN WITH CA+ ON X-RAY FROM PSOMMOMA BODIES
MALIGNANT LESIONS–RARE—2ND LEADING CAUSE OF DEATH IN PEDS (TRAUMA #1)
RISK FACTORS ARE Fhx, RT, PREVIOUS TUMORS, IMMUNOCOMPROMISE
IN THE NECK SUPRACLAVICULAR AND POST TRIANGLE LESIONS ARE MORE COMMON
MESODERMAL
LEUKEMIA AND CNS CANCERS ARE #1
LYMPHOMA = 12% (3RD)—–60% OF SUPRACLAVICULAR LAD IN PEDS IS LYMPHOMA—PUSH FOR EARLY BIOPSY
SARCOMA=8%(4TH)
ECTODERMAL
EPITHELIAL (SQUAMOUS CELL) TUMORS ARE RARE IN PEDS
SALIVARY GLAND TUMORS ARE ALL ECTODERMAL
ADNEXAL TUMORS
SEBACEOUS GLAND=MOST COMMON
—-OF THE MEIBOMIAN GLAND—USUALLY PRESENT AS ULCERATED NODULAR LESOIN OF THE PALPEBRAE
SWEAT GLAND
APOCRINE OR ECCRINE GLAND CA
HAIR FOLLICLES
TRICHOLEMMAL CA OR MALIGNANT TRICHOLFOLLICULOMA
PILOMATRIXOMA—”OF MALHERBE”
NEUROECTODERMAL—NEURAL CREST CELL TUMORS
NOTOCHORD= STRUCTURAL VESTIGE FORMED FROM MESODERM–CLIVAL OR SACRAL CHORDOMA
EVENTUALLY BECOMES THE NUCLEUS PALPOSUS—VERTEBLRAL COLUM FORMS AROUND IT
STIMULATES NEURULATION PROCESS IN THE OVERLYING NEUROECTODERM
NEURULATION—-SOME OF THE NEUROECTODERM SEPERATES AN MIGRATES OUT TO FORM PERIPHERAL NEURAL STRUCTURES:
AFFERENT–DORSAL ROOT GANGLION
AUTONOMIC GANGLION—-SYMPATHETIC TRUNK, CN 3, 7, 9, AND 10 (GLOMUS CELL TUMORS—PARAGANGLIOMAS)
ADRENAL MEDULLA (CHROMAFFIN CELLS)—PHEOCHROMOCYTOMA, CHROMAFFINOMA
CELIAC,RENAL, INTESTINAL PLEXUS
SCHWANN CELLS(MYELINATE THE PNS)—-SCHWANNOMA
MENINGES—PIA AND ARACHNOID (MENINGIOMA)
PIGMENT CELLS—-MELANOMA
IRIS CHROMATOPHORES
MERKEL CELL CA
ULTIMOBRANCHIAL BODY—-PARAFOLLICULAR C-CELLS OF THE THYROID—-MEDULLARY CA OF THE THYROID
GRANULAR CELL TUMOR (DORSAL TONGUE)
NEUROBLASTOMA
ESTHESIONEUROBLASTOMA (OLFACTORY NEUROBLASTOMA)
NEUROECTODERMAL TUMOR OF INFANCY
CUTANEOUS TUMORS OF NERVES AND NEUROENDOCRINE CELLS
NEUROFIBROSARCOMA
GLOMUS CELL TUMOR——SYMPATHETIC INNERVATION—-REGULATES THE SUEQUET HOYER CANAL
TRAUMATIC:
IDIOPATHIC:

Posted by: on