Section 13


For each level: Give a differential diagnosis for a neck lump in that area apart from a lymph node; Give a differential diagnosis for a neck lump in that area apart from a lymph node

Answer

LevelDifferential diagnosis for neck lumpPrimary tumour site for which this level are the first echelon nodes
I

submandibular gland pathology, 

tooth abscess, ranula, osteosarcoma

Oral cavity

submandibular and sublingual glands

IIparotid pathology e.g. parotitis, pleomorphic adenoma, branchial cyst

oral cavity

Nasopharynx

larynx, pharynx

submandibular and sublingual glands

parotid

III

branchial cyst, paragangliomas eg carotid body tumour, carotid graft infection (eg post carotid endarterectomy)

ra

oral cavity

larynx, pharynx

submandibular and sublingual glands

IVparagangliomas

larynx

pharynx

Vcystic hygromathyroid
VIthyroid goitre/nodule, thyroglossal duct cyst, dermoid and epidermoid cysts, thymic cystthyroid


POSSIBLE DIAGNOSES BY LEVEL (ANATOMICAL SIEVE)

Anywhere: Lymph node; ‘think’ a) reactive eg tooth abscess or systemic infection; b) infective eg tuberculosis or toxoplasmosis; c) neoplastic eg lymphoma or metastasis. Feel for other lymph nodes in the axilla and groin.

Sebaceous cyst, lipoma, skin neoplasms eg basal cell carcinoma, sarcoid nodule, lymphangioma (cystic hygromas are usually Level V but can be found anywhere)

Level I: submandibular gland pathology, tooth abscess, ranula, osteosarcoma

Level II: parotid pathology, branchial cyst.

 If over 40 then metastatic SCC until proven otherwise. If <40 anterior triangle then branchial cyst. 

Level III: branchial cyst, paragangliomas eg carotid body tumour, carotid graft infection (eg post carotid endarterectomy)

Level IV: paragangliomas

Level V: cystic hygroma

Level VI and midline: thyroid goitre/nodule, thyroglossal duct cyst, dermoid and epidermoid cysts, thymic cyst

Branchial cyst- lymphoid tissue, lined by squamous epithelium. Thought to arise from squamous cells left in lymph nodes. Present early adulthood. Treatment, conservative, abx for infections, surgical excision.  

Thyroglossal duct cyst- 

  • Presents in childhood- midline swelling (89%) 10% left side, 1% right, cystic, moves up on tongue protrusion. May cause pain/intermittent swelling from infections, dyspnoea, dysphagia
  • Persistent duct from the migration of the thyroid gland from the tongue base to anterior trachea
  • Ix- USS neck, Radio-iodine scan to look for ectopic thyroid tissue, MRI neck
  • Excision-Sistrunk’s procedure remove body of hyoid bone otherwise 85% recurrence rate
  • Sistrunks complication- haematoma–>ludwig’s angina picture

POSSIBLE DIAGNOSES BY SURGICAL SIEVE

Congenital:

  • Lymphangioma (including cystic hygroma)
  • Branchial cyst
  • Thyroglossal duct cyst
  • Dermoid and epidermoid cysts
  • Thymic cyst

Acquired

  • Vascular: paraganglioma, carotid aneurysm, carotid graft infection (eg post carotid endarterectomy)
  • Infective: reactive lymphadenopathy, toxoplasmosis, tuberculosis, actinomycosis
  • Inflammatory/granulomatous: sarcoidosis
  • Idiopathic: ranula
  • Neoplastic: lymphoma, thyroid neoplasm, salivary neoplasm, lymph node metastasis from aerodigestive tract primary, skin neoplasms eg basal cell carcinoma
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