Neck masses, neck infection
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In the workup of a midline neck mass, what is the role of radionuclide scanning?
- Can differentiate functioning from nonfunctioning tissue and thus can be considered in the workup of a lingual thyroid or thyroglossal duct cyst, where the presence of normal functioning thyroid tissue must be determined.
- Can also be considered in the workup of salivary gland pathology because lesions can be localized to within or outside of the major salivary glands.
In a pt with HIV, diffuse lymphadenopathy is common, but a growing or domi-nant mass should raise suspicion for what process?
The most common head and neck malignancies in the pediatric population.
- The second most common overall head and neck malignancy, second only to squamous cell carcinoma.
Which is more common, Hodgkin's or non-Hodgkin's Lymphoma? which is more likely to present with cervical nodal disease?
- Non-Hodgkin's lymphoma is approximately five times more common in the head and neck.
- Eighty percent of patients with Hodgkin's disease have cervical nodal disease.
- 33% of those with non-Hodgkin's disease have nodal disease.
- Greater than 90% of non-Hodgkin's lymphomas, are of B-cell origin.
What are “B” symptoms?
Those symptoms that, when found, upstage the patient. They are unexplained fever, unexplained weight loss, and night sweats.
Rates of malignancy in salivary neoplasms (by involved gland).
- Parotid 20%
- Submandibular 50%
- Sublingual >75%
- Malignancy is more common in children (35% overall)
How would one differentiate a vagal schwannoma from a carotid body tumor based on the position of the carotids?
When located in the carotid sheath, schwannomas will displace the internal and external carotid arteries anteriorly, a feature distinguishing them from carotid body tumors (which demonstrate alyre sign).
What is the most common extracranial solid tumor in children?
- Neuroblastoma. Causes 8% to 10% of all childhood malignancies.
- Primary cervical neroblastomas are seen rarely, cervical metastases from intra-abdominal neuroblastomas are the more common presentation in the head and neck.
Three main locations of paragangliomas.
- Carotid body, jugulotympanic region, and vagus nerve.
- These are highly vascular, slow-growing, mostly benign lesions.
What percentage of paragangliomas are malignant? Heritable? Multicentric?
- Less than 10% thought to be malignant
- Approximately 10% occur in an inherited pattern (autosomal dominant) or are associated with a syndrome (multiple endocrine neoplasia IIA or IIB, or von Hippel– Lindau disease)
- 10% occur as multicentric lesions
Characteristic MRI findings of paragangliomas
Paragangliomas have a distinct “salt and pepper” appearance on T1-weighted MR images due to their vascular flow-voids.
During panendoscopy for unknown primary, which sites should have directed biopsies?
nasopharynx, tongue base and tonsillar fossae, and hypopharynx.
Ipsilateral tonsil has been found to harbor the occult primary in what percentage of cases of unknown primary?
- Base of tongue is next most common
Describe type 1 and 2 first branchial cleft anomalies.
- Type 1 first branchial cleft anomalies are duplications of the external auditory canal and often have attachments to the skin of the external auditory canal or to the tympanic membrane. These lesions contain ectodermal elements only. Run lateral to the branches of the facial nerve.
- Type 2 first branchial cleft anomalies, however, contain ectoderm and mesoderm. These anomalies can often contain cartilage elements. Often course deep to the facial nerve and its branches.
What is the most common age and location or the presentation of a lymphangioma (lymphatic malformation)?
Half of all lymphangiomas are present at birth, and 90% are present by the age of 2. Most commonly seen in the posterior triangle.
A history of maternal polyhydramnios has been noted in what percent of neonates who have a cervical teratoma?
An implant of thymic tissue along the descent tract anywhere in the neck (more commonly on the left) may result in a thymic cyst. What histologic finding is pathognomonic for this tissue?
Antibiotic of choice or cat scratch (bartonella henselae)?
Antibiotic therapy with azithromycin, an aminoglycside, or ciprofloxacin is usually curative.
Clinical criteria for Kawasaki's.
Fever persisting for 5 days and four of the following features: (1) acute, nonpurulent cervical lymphadenopathy that is usually unilateral; (2) erythema, edema, and desquamation of the hands and feet; (3) polymorphous exanthem; (4) bilateral painless conjunctival infection; and (5) erythema and infection of the lips and oral cavity.
6 year old boy with massive cervical adenopathy, fever, and skin nodules. Biopsy of lymph nodes shows dilated sinuses, many plasma cells, and marked proliferation of histiocytes. What is the appropriate management of this patient.
Sinus Histiocytosis (Rosai-Dorfman Disease) is thought to represent an abnormal histiocytic response to some precipitating cause, possibly either a herpesvirus or EBV. Management of this disorder is expectant.
Most common pediatric soft tissue malignancy of the head and neck.
- Embryonal rhabdomyosarcoma is the most common cell type, followed by alveolar and pleomorphic
Deep neck space infection
- Muscles enveloped by the superficial cervical fascia?
- The platysma and muscles of facial expression
Structure enveloped by the superficial layer of the deep cervical fascia?
- Surrounds the trapezius and sternocleidomastoid muscles
- Parotid gland
- submandibular gland
- muscles of mastication
- forms the stylomandibular ligament and contributes to the carotid sheath
Structure enveloped by the middle layer of the deep cervical fascia?
The muscular division surrounds the strap muscles (sternohyoid, sternothyroid, thyrohyoid, omohyoid). The visceral division surrounds the buccinator, pharyngeal constrictor muscles, larynx, trachea, esophagus, thyroid, and parathyroid glands.
Structure enveloped by the deep layer of the deep cervical fascia?
- Divides into two layers: the prevertebral and alar layers.
- The prevertebral layer envelops the paraspinous muscles and cervical vertebrae. Extends from the skull base to the coccyx. It covers the scalene muscles and forms the floor of the posterior triangle.
- Splits to form the alar layer which lies between the prevertebral layer and the buccopharyngeal fascia of the visceral middle layer. The alar fascia separates the retropharyngeal and danger spaces.
Boundaries of the parapharyngeal space?
- Inverted pyramid with its superior base at the skull base and its inferior apex at the greater cornu of the hyoid bone.
- Anteriorly: The pterygomandibular raphe and medial pterygoid muscle
- Posteriorly: the prevertebral fascia
- Medially: The superior constrictor, tensor, and levator veli palatini muscles
- Laterally: parotid gland, mandible, and lateral pterygoid muscle
Infections of which tooth roots can lead to ludwigs angina?
The mylohyoid line determines the most likely route of odontogenic infectious spread. The teeth apices anterior to the second molar lie superior to the mylohyoid line and thus involve the sublingual space. Infections of the second and third molars initially involve the submandibular or parapharyngeal space, because their roots extend below the mylohyoid line.
Define the retropharyngeal space. What is its inferior limit?
The retropharyngeal space extends from the skull base to the mediastinum at the tracheal bifurcation. It is a potential space between the middle and deep layers of deep cervical fasciae, anterior to the alar fascia of the deep layer and posterior to the buccopharyngeal fascia of the middle layer that lines the posterior pharynx and esophagus.
Define the danger space in the neck. What is its inferior limit?
Extends from the skull base to the diaphragm. This potential space lies between the retropharyngeal and prevertebral spaces. The deep layer of deep cervical fascia subdivisions bound this space. The alar layer forms its anterior border, and the prevertebral layer forms its posterior border.
Transmission of infection into the masticator space is most commonly from which teeth?
the third mandibular molars
At the level of C2 on lateral neck film, what amount of prevertebral thickening is indicative of a retropharyngeal abscess?
- greater than 5 mm of thickening in a child
- greater than 7 mm of thickening in an adult
- Air fluid level
What percentage of adults and children develop a new PTA after their first episode?
Approximately 16% of adults and 7% of children will experience a recurrent peritonsillar abscess at a later date after an initial episode.
Lemierre's syndrome is most often caused by which organism?
- Thrombophlebitis of the internal jugular vein
- Pharyngitis progresses to fever, lethargy, lateral neck tenderness and edema, occasional trismus, and septic emboli.
- Anaerobic, gram-negative bacillus Fusobacterium necrophorum.
35 year old male with 1 week of left facial pain and nasal congestion c/o fever, lethargy, blurry vision, orbital pain. Exam shows proptosis, reduced extraocular mobility, and dilated pupil with sluggish pupillary light reflex.
- Concern for abscess, but also cavernous sinus thrombosis
- Cavernous sinus thrombosis has a mortality rate of 30% to 40%
- Caused by retrograde spread of infection from the upper dentition or paranasal sinuses via the valveless ophthalmic venous system to the cavernous sinus.
- Confirmed by MRI brain with contrast to demonstrate dural enhancement.
- Treatment includes critical care life support, broad-spectrum IV antibiotics, and anticoagulation therapy.
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