بحث طبى انجليزى– أورام الرقبة –كتبته بنفسى English-–Neck Swellings

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بحث طبى انجليزى– أورام الرقبة –كتبته بنفسى English-–Neck Swellings

(لو وجد اخطاء فى هجاء بعض الكلمات –صحح اخطاء الكلمة فى جوجل ترجمه )

(if you find mistakes in the spelling of few words, you can correct the mistakes on google translation)

HISTORY

Age:- some congenital anomalies , such as branchial fistula, are present since birth while others such as branchial cyst , cystic hygroma and thyroglossal cyst and fistula appear in childhood or even in adult life.. inflammatory swellings, cysts and benign tumours can occur at any age but secondary carcinoma in lymph nodes is a disease of old age.

Compliant :- if the patient presents with a swelling, note its duration and the presence of any primary focus, pressure symptoms or general effects.. remember that the majority of swellings in the neck arise in the thyroid gland or in the cervical lymph nodes.

Past history :- inquire about any history of tuberculosis or primary focus in the drainage areas…in congenital torticollis,, there is often a history of "sternomastoid tumour", difficult labour or both… if there is a sinus, inquire about previous swelling, mode of onset and character of the discharge…

General examination

In any affection of the cervical lymph nodes, examine all other other gland groups in the body as well as the chest (tuberculosis or metases) and abdomen (liver and spleen)..in addition, the scalp, face, mouth, throat, spine, axillae, breasts and chest should be thoroughly examined to disclose any inflammatory or malignant primary focus.

Local Examination

1- swelling :- Number and site :- multiple swellings are usually due to enlarged lymph nodes…most swellings in the thyroid region arise in the thyroid gland it self whereas swellings outside this area are most often due to enlarged lymph nodes…in the submandibular triangle, besides enlarged lymph glands, the swelling may prove to be an enlarged salivary gland, deep or plunging ranula, lateral sublingual dermoid cyst or a downward extension of a manibular swelling…some swellings have characteristic sites, e.g. branchial cyst just below the angle of the jaw; carotid body tumour under the anterior border of the sternomastoid at the level of the upper border of the thyroid cartilage; carotid aneurysm in the line of the carotid vessels;sternomastoid tumour in the substance of the muscle ; and cystic hygroma in the lower part of posterior triangle.

ابحث فى الانترنت عن هذه الرسومات

Search on internet and look for these drawings

(enlarged lymph nodes due to Hodgkin's disease)

(lymphosarcoma of the neck )

b- Characters :- Inspect and palpate the swelling thoroughly, noting its size, shape, surface, edge, consistency and mobility…most swellings of the neck are best palpated from behind with the head slightly flexed and bent towards the side of the lesion…in cystic swellings, note the presence of pulsation and examine the swelling by percussion, auscultation and transillumination……a tympanitic note is obtained only over a laryngocele --- a very rare condition, and a bruit may be heard over an aneurysm or carotid body tumour…..

c- Relations :- determine the relationships of the swelling to the sternomastoid muscle, carotid sheath, larynx and trachea…

If the swelling lies in the region of the sternomastoid muscle, instruct the patient to contract the muscle by pushing his chin against your hand and note wether the swelling becomes more (superficial) or less prominent (deep) on contraction of the muscle….palpate the contracted muscle from below upwards and note wether it courses beneath or over the swelling…. Test the mobility of the swelling in relation to the contracted muscle to determine whether the muscle is free from or attached to the swelling…

Palpate the carotid pulsation from below upwards and note the relation of the swelling to the carotid sheath….. test for movement of the swelling on swallowing and protrusion of the tongue…upward movement on deglutition indicates that the swelling is attached to the hyoid bone, larynx or trachea, e.g. thyroid swellings, thyroglossal cysts, subhyoid bursitis or dherent lymph nodes….on the other hand, movement on protrusion of the tongue is shown only swellings attached to the hyoid, e.g. subhyoid bursitis and thyroglossal cyst….

2- skin:- Examine the skin for signs of inflammation, e.g. redness and oedema, or malignancy, e.g. dilated veins, dimpling puckering or fungation….

Look for any ulcer, sinus or fistula and examine it thoroughly as detailed in the appropriate schemes….branchial fistula opens typically at the lower third of the anterior border of the sternomastoid by a tiny orifice discharging clear mucus…Tuberculous sinuses are common in the upper part of the neck and the surrounding skin is often the seat of tuberculous ulcers and , sometimes, healed linear transverse scars….in thyroglossal fistula, the orifice lies close to the midline below the hyoid and is often indrawn and overlaid by a crescentic fold of skin…A solitary sinus close to the jaw is often due to osteomyelitis of the mandible whereas multiple sinuses over an indurated mass in the upper part of the neck are suggestive of actionmycosis and the diagnosis is confirmed by the finding of sulphur granules in the pus….

3- lymph nodes : always conduct this examination from behind and follow a systematic order to avoid missing any enlarged lymph node… palpate first the circular groups in this order : submental, submandibular, parotid (including the preauricular gland ) mastoid and occipital…next palpate the vertical chins: anterior jugular ( prelaryngeal, pretracheal and suprasternal), external jugular (superficial to the sternomastoid) and internal jugular (deep cervical glands) and finally the glands of the posterior triangle ( the accessory and supraclavicular groups)..

If any glands are enlarged, note their number, site, arrangement, characters and relation to each other and to surrounding structures… next scrutinize their drainage areas as follows : a-submental glands : chin, lowerlip, floor of the mouth and tip of the tongue; (b) submandibular glands; lips, cheek, tongue, floor of the mouth, palate, nose and maxillary antrum ; (c) upper deep cervical glands : tongue, mouth, tonsils, pharynx, larynx and thyroid ; (d) lower deep cervical and supraclavicular glands ; thyroid, breast, chest, axillae and on the left side ( Troisier's glands), the abdomen, pelvis and scrotum as well ; (e) Mastoid, occipital and accessory glands : scalp, adenoid area and ear…finally examine the chest for evidence of tuberculosis and metastases and palpate all other lymph gland groups in the body (axillary, mediastinal, abdominal and linguinal ) and the liver and spleen as well….

4- Face, mouth and throat :- the cervical lymphnodes drain the scalp, face, mouth and throat and if the cervical swelling is suspected to be a mass of enlarged lymph nodes, these parts should be scrutinized for evidence of an inflammatory or malignant primary focus…

b) in malignant lesions of the neck, look for Horner's syndrome which indicates involvement of the cervical sympathetic trunk… in carcinoma of the nasopharynx, by the time a mass of metastatic lymph nodes appears in the neck, the primary tumour has invaded the sphenoid fissure with involvement of the third fourth, ophthalmic division of the fifth and sixth nerves… ptosis, opthalmoplegia and a mass of cancerous glands in the neck, therefore, signify that the primary growth lies in the nasopharynx….

5. spine : in torticollis and cold abscess of the posterior triangle, examine the back and sides of the neck for rigidty, tenderness and muscle spasm and test the movements of the head and neck….in caries of the cervical spine, flexion, extension and lateral bending are limited: rotation is also limited if the atlanto- occipital joint is involved….

Special investigation

1- aspiration is very useful in the diagnosis of cystic swellings.

2- Endoscopy is helpful in searching for a primary lesion in the nose, ear, pharynx, larynx, oesophagus and bronchus…

3- X-rays :- (a) cervical spine for caries and cervical rib; (b) chest for tuberculosis, secondary deposits and enlarged mediastinal glands : c) fistulography for sinuses and fistula ..in branchial fistula, the track is uniform and definite and may extend to the supratonsillar fossa whereas the track of a thyroglossal fistula is tortuous , fragmented and can rarely be demonstrated beyond the hyoid bone.

4- Biopsy for enlarged lymph nodes of doubtful nature…

Differential Diagnosis of swelling of the neck

Solid swelling

1- Enlarged lymph nodes

2- thyroid swellings

3-swellings of the submandibular salivary gland.

These are the commonest swellings and are fully dealt with in the appropriate schemes.

4- Rare swellings which include : (a) cervical rib : a bony hard swelling just above the clavicle with prominent subclavian pulsations and distal neurovascular phenomenon in the upper limb....X-ray examination usually settles the diagnosis (b) sternomastoid tumour :- a hard fusiform swelling in the lower part of the sternomastoid of a newly borne infant...it remains stationary until the third month and then gradually disappears.... it is followed by congenital torticollis which makes its appearance between the ages of five and seven years. (c) carotid body tumours occur in middle-aged people as a hard, ovoid swelling which exhibits transmitted or expansile pulsation and can be moved transversely but not vertically......A few patients complain of attacks of faintness and sometimes , pressure on the tumour causes slowing of the pulse and fainting (carotid body syndrome)...carotid arteriography is the best means of confirming the diagnosis.... (d) cervical neurofibroma may arise from the cervical sympathetic chain or from the vagus, glossopharyngeal and spinal nerves (e) branchiogenic carcinoma is a very rare epitheliomatous tumour, sometimes mixed with lymphoid tissue, which arises from branchial remanants and lies deep to the upper part of the sternomastoid....nowadays, the existence of such lesion is very doubtful since lymphatic metastases from papillary carcinoma of the thyroid have a similar histological picture... it should never be diagnosed until every possible source of a primary growth has been eliminated ..perhaps the only solid proof of the diagnosis is survival of the patient for 5 years without symptoms after removal of the growth...

MIDLINE CYSTS

1-Dermoid cysts occur as sequestration dermoids in the middle line, either below the chin (sublingual dermoid ) or at the suprasternal notch (suprasternal dermoid )...the cyst forms a soft fluctuant subcutaneous swelling, opaque on transillumination.

2- thyroglossal cyst usually occurs below the hyoid bone as a rounded swelling which grows very slowly in size... it moves upwards on deglutition and on protrusion of the tongue, as it is attached to the hyoid bone.. in the course of time suppuration occurs and leads to the formation of a thyroglossal fistula...

3- cold abscess may form in the submental region from the breaking down of tuberculous submental glands, or in the suprasternal notch from tuberculosis of the manubrium... the abscess may be associated with enlarged glands or evidence of tuberculosis of the sternum....it is fixed in its bed and rather irregular in shape...it is often surrounded by a zone of induration and the overlying skin may be fixed or reddened....

4- subhyoid bursitis forms a sausage- shaped cystic swelling, just below the lower border of the hyoid bone, bulging down from the normal position of the bursa between the thyroid membrane and the posterior surface of the hyoid bone...

5- laryngocele is a hernia of the laryngeal mucosa through a gap in the thyroid membrane , which occurs in players of wind instruments... it forms a tense resonant swelling in the lower part of the neck, which is translucent and compressible, and enlarges greatly when the patient blows with the mouth closed and the nose obstructed....

6- Cystadenoma of the thyroid isthmus forms a swelling below the cricoid which moves with deglutition and merges into the thyroid...

Lateral cysts

1- cystic hygroma forms a large, lobulated soft translucent swelling, sometimes with deeply placed intermuscular projections... it is often present at birth, and usually lies in the lower third of the neck extending downwards behind the clavicle to lie upon the dome of the pleura or to appear in the axilla...

2-branchial cyst appears in adolescence as a rounded smooth cystic swelling in the upper part of the neck, just below the angle of the jaw and deep to the sternomastoid…

3-sebaceous cyst may develop in the skin of the neck as else where.

4- cold abscess occurs most often in the upper part of the neck in relation to tuberculous lymph nodes…it forms a cystic swelling with indurated edges and fixed base…matted glands are often palpable around and deep to the abscess..

In caries of the cervical spine with retropharyngeal abscess, the pus often tracks along the nerve roots and presents in the posterior triangle as a soft compressible fluctuating swelling….

5- lipoma forms a soft lobulated painless swelling exhibits pseudofluctuation…

6- Lymphangioma may occur in children as a soft, lobulated translucent swelling…

7- Haemangioma is rare and forms a similar swelling but the surface is bluish and the swelling is compressible and opaque on transillumination…

8- blood cysts usually occur in connection with the veins of the neck, probably from dilatation of venous channels… the cyst is compressible and opaque on transillumination…

9- Aneurysms may arise in connection with the main arteries of the neck…

10- pharyngeal pouch may appear in the neck behind the sternomastoid muscle, usually on the left side…

11- Cystadenoma of the thyroid lobe forms a cystic swelling attached to the larynx and moving on deglutition….

12- Degenerative cysts may occur in cancerous glands or malignant tumours of the neck…

13- Hydatid cyst very rarely occurs in the neck….