neck mass pop
TRANSCRIPT
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ProblemProblem--base learningbase learning
Neck MassNeck Mass
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CaseCase : 40
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ChiefComplaint : 4
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Present illness
4 PTA
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Past history
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MoreHistory ?
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PhysicalPhysical
examinationexamination
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Physical examinationPhysical examination
GAGA::AA thaithai female, good consciousness,female, good consciousness,notnot pale,nopale,no jaundicejaundice
Vital signs :Vital signs :
BT =BT = 3737..22 00CC BP =BP = 120120//8080 mmHgmmHg
RR =RR = 1616/min/min PRPR== 8484 bpmbpm
Heart & lungHeart & lung :: normalnormal
AbdomenAbdomen :: liver and spleen cant beliver and spleen cant bepalpatedpalpated
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ENT examENT exam
NoseNose : normal: normal
NasopharynxNasopharynx : no polyp , no mass seen,: no polyp , no mass seen,nono discharge, not injected,discharge, not injected, notnot swellingswelling
OropharynxOropharynx : tonsil arent enlarged, dental: tonsil arent enlarged, dental caries,caries,nono ulcer, not injected ,ulcer, not injected ,nono swellingswelling
IDLIDL : vocal cord normal movement,: vocal cord normal movement,no noduleno nodule , not injected, not injected
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NeckExaminationNeckExamination
Thyroid gland not enlargementThyroid gland not enlargement
Parotid glandParotid gland normalnormal
Neck mass: (more info next slide)Neck mass: (more info next slide)
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Positive findingPositive finding
HxHx::
44 PTAPTA
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Positive findingPositive finding
PE.PE.
Neck mass :Neck mass :At posterior triangle, irregular surface,
firm, not tender, movable, no sign of inflammation,
no translucency
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Mass :
- posterior triangle
- irregular surface- firm
- not tender
- movable
- no sign of inflammation- no translucency
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Approach to neck massApproach to neck mass
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Neck massNeck mass
IncidenceIncidence
AgeAge
SexSex Duration (Rule of seven)Duration (Rule of seven)
PainPain
General symptomsGeneral symptoms
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EtiologyEtiology
0-15 years 16-40 years >40 years
Inflammatory Inflammatory Malignant
Congenital
developmental
Congenital
developmentalBenign
Neoplasm-
malignant Neoplasm-benign Inflammatory
Benign MalignantCongenital
developmental
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Medical Student Gr. 5A
Rule ofRule of 8080ss
Older thanOlder than 4040 yearsyears oldold
8080% of all% of all nonthyroidnonthyroid neck masses areneck masses are neoplasticneoplastic
8080%of these
%of these neoplasmsneoplasms are malignantare malignant
8080% of these malignant lesions are metastatic lesions% of these malignant lesions are metastatic lesions
8080% of these metastatic lesions arise from primaries% of these metastatic lesions arise from primaries
that are above the claviclethat are above the clavicle
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History of cancerHistory of cancer
,,,, 44-- 66
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Physical examinationPhysical examination
Local examinationLocal examination
Regional examinationRegional examination
General examinationGeneral examination
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Local examinationLocal examination
Location (midline or lateral)Location (midline or lateral)
SizeSize
ShapeShape SurfaceSurface
ConsistencyConsistency
TendernessTenderness MobilityMobility
PulsationPulsation
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Midline massMidline mass
ThyroglossalThyroglossal duct cystduct cyst
Isthmus of thyroidIsthmus of thyroid
Pharyngeal pouchPharyngeal pouch SubhyoidSubhyoid bursabursa
DelphianDelphian nodenode
LaryngoceleLaryngocele Ectopic thyroidEctopic thyroid
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Lateral neck massLateral neck mass
NonNon--lymph nodelymph node
Lymph nodeLymph node
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NonNon--lymph nodelymph node
Solitary thyroid noduleSolitary thyroid nodule
Branchial cleft anomaliesBranchial cleft anomalies
Cystic hygromaCystic hygroma Carotid body tumorCarotid body tumor
LipomaLipoma
NeurilemmomaNeurilemmoma Swelling of salivary glandSwelling of salivary gland
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Lymph nodeLymph node
InfectionInfection
--acute (pyogenic)acute (pyogenic)
--chronic (Tuberculosis,atypicalchronic (Tuberculosis,atypicalmycobacterium,cat scrath fever)mycobacterium,cat scrath fever)
Primary neoplasmPrimary neoplasm
-- Hodgkins lymphomaHodgkins lymphoma-- NonNon--HodgkinsHodgkins
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Lymph nodeLymph node
Metastatic nodeMetastatic node
-- Head and neck cancerHead and neck cancer
-- BelowBelow clavicularclavicular cancer (cancer (lung,GI,etclung,GI,etc.).)-- Unknown primaryUnknown primary
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Lymph node drainageLymph node drainage
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Cervical node region and possible origin
of primary neoplasm
Lymph node Primary
Submandibular
Posterior cervical
Supraclavicular
Upper jugular
Middlejugular
Low jugular
Lower lip,floor of mouth,tongue
(anterior),Tonsil,buccal mucosa,gingiva
Nasopharynx,thyroid,lateral pharyngeal wall
Below the clavicle
Tongue(lateral and posterior),palate,tonsil
Pharynx,larynx,piriform sinus,thyroid
Esophagus (cervical segment)
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InvestigationInvestigation
CBCCBC
Chest XChest X--rayray
FlexibleFlexible rhinolaryngoscoperhinolaryngoscope,, nasopharyngoscopenasopharyngoscope UltrasonographyUltrasonography
DirectDirect laryngoscope,bronchoscopelaryngoscope,bronchoscope,,
esophagoscopeesophagoscope
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InvestigationInvestigation
Fine needle aspirationFine needle aspiration
Sialography,MRISialography,MRI
BiopsyBiopsy Syphilis,AIDSSyphilis,AIDS
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Diffential diagnosisDiffential diagnosis
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Diffential diagnosisDiffential diagnosis
Lymphoma ( primary neoplasm )Lymphoma ( primary neoplasm )
TuberculousTuberculous lymphadenitislymphadenitis
Metastatic lymph node neoplasmMetastatic lymph node neoplasm LipomaLipoma
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lymphomalymphoma
NonNon--hodgkinshodgkins ProgressiveProgressive clonalclonal expansion Bexpansion B--cell , Tcell , T--cell , NKcell , NK
m/c hematopoietic neoplasm (m/c hematopoietic neoplasm ( 55 times of HD )times of HD ) PainlessPainless adenopathyadenopathy , fatigue and weakness, fatigue and weakness
B symptoms : fever , night sweat , lost weightB symptoms : fever , night sweat , lost weight
HepatosplenomegalyHepatosplenomegaly Noncontiguous pattern of spreadingNoncontiguous pattern of spreading
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Hodgkins diseaseHodgkins disease
Predominant BPredominant B--cellcell malinancymalinancy
Bimodal age distribution :Bimodal age distribution : 33rd decade , aroundrd decade , around 6060
Common present with cervicalCommon present with cervical adenopathyadenopathy B symptom ,B symptom , pruritispruritis ,, hepatosplenomegalyhepatosplenomegaly ,,
PelPel EbsteinEbstein fever , Alcoholfever , Alcohol--induced pain ( rareinduced pain ( rare
butbut hignhign specificity )specificity ) contiguous pattern of spreadingcontiguous pattern of spreading
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TuberculousTuberculous lymphadenitislymphadenitis
m/c site : neck along them/c site : neck along the sternocleidomastoidsternocleidomastoid m.m.
, posterior cervical and, posterior cervical and supraclavicularsupraclavicular sites.sites.
The most common presentation ofThe most common presentation ofextrapulmonaryextrapulmonary tuberculosistuberculosis
Painless , Advanced may suppurate and form aPainless , Advanced may suppurate and form a
drainagedrainage particularly frequent among HIVparticularly frequent among HIV--infectedinfected
patientspatients
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lipomalipoma
BenignBenignAll age m/c adultAll age m/c adult
Soft , not tenderSoft , not tender
slippery , not attach to skinslippery , not attach to skin
Vary of sizeVary of size
Solitary nodule is commonSolitary nodule is common
Treatment : conservative except tender or rapidTreatment : conservative except tender or rapid
growth (growth ( SxSx common for cosmetics ) ,common for cosmetics ) ,
liposuctionliposuction recurrentrecurrent
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InvestigationInvestigation
investigateinvestigate
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InvestigationInvestigation
CBCCBC
Chest X rayChest X ray
FNABFNAB
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HbHb 1111..99 g/dL , Hctg/dL , Hct 3434..33%%
WBC countWBC count 99,,500500//LL WBC differentialWBC differential
NeutrophilNeutrophil 6363 %%
LymphocyteLymphocyte 3232 %% Atypical LymphocyteAtypical Lymphocyte 22%%
MonocyteMonocyte 22 %%
RBCRBC 55..33 xx 101066 //LL PleteletPletelet 350350,,000000//LL Normocytic normochromic RBCNormocytic normochromic RBC
CBCCBC
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Chest XChest X--rayray
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FNAFNA
Moderate amount of small matureModerate amount of small mature
lymphocytelymphocyte
A few plasma cellA few plasma cell
No evidence of malignancy seenNo evidence of malignancy seen
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Manageme
nt
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Neck mass
Hx & PEENT exam
Biopsy
CXRCBCFNA
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+
+
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Panendoscope
Biopsy 4-5 points+ Nasopharynx exam , biopsy
PF
BOT
Supraglottis
Tonsils
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PanendoscopeBiopsy 4-5 points
+ Nasopharynx exam , biopsy
Unknown 10
Open biopsy
+ frozen Section
+ Radical neck dissection , chemo
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Management nextManagement next
Excisional biopsyExcisional biopsy
Management
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ExcisionalExcisional biopsybiopsy
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Pathology finding : 4xPathology finding : 4x
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Pathology finding :Pathology finding : 1010xx
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Pathology finding 40xPathology finding 40x
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Pathology findingPathology finding 4040xx
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Whats definite diagnosis?Whats definite diagnosis?
Tuberculous lymphadenitisTuberculous lymphadenitis
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TreatmentTreatment
Anti TB drugsAnti TB drugs
Supportive treatmentSupportive treatment educationeducation
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TheEnd.Thank for yourattention
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QuestionQuestion
11.. midlinemidlineneck massneck mass 33 lateral neck masslateral neck mass 33
22..neck massneck mass
((congenital,infection,trauma,tumorcongenital,infection,trauma,tumor
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QuestionQuestion 33..malignancymalignancy
44.Investigation.Investigation
55..malignancymalignancyexcisionalexcisionalbiopsybiopsy biopsybiopsyprimary lesionprimary lesion