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口腔診斷學. Mass in the Neck. 頸部腫脹. 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw. 學 習 目 標. 明白頸部腫脹之鑑別診斷. 參考資料. References:. Wood, Goaz. Differential Diagnosis of Oral Lesions. Mosby Publisher, 3 rd Edition, Chapter 29, 634-5. 自購網路資源: super_toolcool

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slide1

口腔診斷學

Mass in the Neck

頸部腫脹

陳玉昆副教授: 高雄醫學大學 口腔病理科

07-3121101~2755

yukkwa@kmu.edu.tw

slide2

學 習 目 標

  • 明白頸部腫脹之鑑別診斷
slide3

參考資料

References:

  • Wood, Goaz. Differential Diagnosis of Oral Lesions. Mosby Publisher, 3rd Edition, Chapter 29, 634-5.
  • 自購網路資源:super_toolcool
  • 網路資源 (anonymous)
  • 口腔影像的臨床診斷,2nd edition, Chapter 12, p.283
  • Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 31, p. 403-414
  • Kaohsiung Medical University Oral Pathology
  • Crispian Scully. Handbook of oral disease - diagnosis and management. Martin Dunitz Publisher, 1st ed. p. 267-8, 376
  • Yeshwant B. Rawal, Carl M. Allen, John R. Kalmar.
  • A nodular submental mass. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:734-7
  • 彼得 史彼爾人. 漢聲雜誌 民國86, 5月, p. 8
  • Carlson ER et al. Neck dissections for oral/head and neck cancer:1906-2006. J Oral Maxillofac Surg 2006;64:4-11
  • Misra S et al. Management of gingivobuccal complex cancer. Ann R Coll Surg Engl 2008;90:546-53
  • WoolgarJ et al. Neck dissections: A practical guide for the reporting histopathologist. Current Diag Pathol 2007;13:499-511
slide4

Mass of the Neck

Constitutes a small %

of the total body area

Contains many vital

anatomic structures

& diverse tissue types

Diverse and varied

pathological lesions

Examination of neck

should be performed

in patient evaluation

Refs. 2, 3, 9

slide5

Mass of the Neck

A rule of thumb for the duration

of the mass

Day (7 days): Inflammatory lesions

Month (7 months): Neoplasm

Year (7 years): Congenital lesions

slide6

Mass of the Neck

Certain lesions are found in discrete

anatomic locations

A knowledge of those lesions

associated with specific regions in the

neck is useful

Regional approach

Mass of nonspecific location

Skin & subcutaneous tissues

within the neck

- mobile skin

- cervical fascia

Ref. 2

slide7

Mass of the Neck

Mass of specific location

Masses in submandibular region

Masses in parotid region

Masses in median-paramedian region

Masses in lateral region

‘Which’ region will have ‘which’ lesions

Ref. 1

submandible

parotid

(para)median

lateral

slide8

1. Submental node

2. Submandibular node

3. Cranial jugular

(deep cervical) node

4. Medial jugular

(deep cervical) node

5. Caudal jugular

(deep cervical) node

6. Dorsal jugular (superficial

cervical) node along accessory n

7. Supraclavicular node

8. Prelaryngeal & paratracheal node

9. Retropharyngeal node

Mass of the Neck

10. Parotid node

11. Buccal node

12. Retroauricular & occipital node

12 cervical lymph nodes

Ref. 1

slide9

Mass of the Neck

Levels I-V: Basis of

the nomenclature for the classification of neck dissections for oral/head & neck cancers

Levels 1-III:

Sentinel LN of

oral cancer

(1st meta LNs)

Refs. 10, 11

slide17

Mass of the Neck

Mass of specific location

Masses in submandibular region

Lymph nodes: first echelon node

- the first node that encounter the

tumor cell or microorganism

Lymph nodes: enlargement

- Infection: lymphoid hyperplasia

: acute lymphadenitis

- metastatic cervical node

- lymphoma

Ref. 1

slide18

Mass of the Neck

Mass of specific location (觸診)

Masses in submandibular region

Lymph nodes: enlargement

- Infection: lymphoid hyperplasia

movable, painless, non-tender

: acute lymphadenitis

movable/fixed, painful, tender

- metastatic cervical node

fixed, painless, non-tender, hard

- lymphoma (solitary/multiple; uni/bilateral)

fixed, painless, non-tender, rubber/firm

Find the

origin

Ref. 1

slide19

Mass of the Neck

Find the origin:

- Infection: lymphoid hyperplasia

: acute lymphadenitis

Infection source- pericoronitis

(third molar)

- infected cyst

- metastatic cervical node

Primary tumor – oral SCC, NPC, others

- lymphoma (solitary/multiple; uni/bilateral)

History, biopsy,imaging examination

Ref. 2

slide20

Mass of the Neck

Mass of specific location

Masses in submandibular region

Submandibular space infection (cellulitis)

Pericoronitis (third molar), infected cyst

Submandibular gland infection (sialadenitis)

Pain & swelling prior to eating

Submandibular gland neoplasm

Biopsy, imaging examination

(sialography, CT)

Ref. 1

slide21

Mass of the Neck

Mass of specific location (觸診)

Masses in parotid region

Enlargedlymph nodes

- Infection: lymphoid hyperplasia

movable, painless, non-tender

: acute lymphadenitis

movable/fixed, painful, tender

- metastatic cervical node

fixed, painless, non-tender, hard

- lymphoma (solitary/multiple; uni/bilateral)

fixed, painless, non-tender, rubber/firm

Locate the

origin

Ref. 1

slide22

Mass of the Neck

Locate the origin:

- Infection: lymphoid hyperplasia

: acute lymphadenitis

Infection source- infected cyst

(congenital preauricular cyst,

sebaceous cyst)

- metastatic parotid node

Primary tumor – oral SCC, NPC, others

- lymphoma (solitary/multiple; uni/bilateral)

Biopsy,imaging examination

Ref. 2

slide23

Ball in hand

Mass of the Neck

Mass of specific location

Masses in parotid region

Parotid gland infection (parotitis)

Stone in Stensen’s duct, virus, bacteria

Parotid gland neoplasm

Benign (70%), malignant (30%)

Biopsy, imaging examination

(sialography, CT)

Refs. 2, 4, 5

slide24

Mass of the Neck

Mass of specific location

Masses in parotid region

Bilateral parotid enlargement

Mikulicz’s disease

Benign lymphoepithelial lesion

(enlargement of parotid, lacrymal glands)

Mickulicz’s syndrome (非lymphoepithelial lesion)

Associated with lymphoma, sarcoidosis, TB

Sjogren’s syndrome

Xerostomia, conjunctivitis, rheumatoid

arthritis

slide25

Xerostomia

Biparotid enlargement

Primary Sjogren syndrome

Xerostomia

Conjunctivitis

sicca

Connective tissue

disease (auto-

immune disease)

Dry eye

Secondary Sjogren syndrome

Mass of the Neck

Ref. 7

slide26

Mass of the Neck

General Data

  • 姓名:杜XX
  • 性別:男
  • 年齡:34歲
  • 出生地:苗栗
  • 居住地:高雄
  • 婚姻狀況:已婚
  • 初診日期:X年X月X日

Ref. 6

slide27

Mass of the Neck

Chief Complaint

  • A swelling mass of R’t parotid area

Ref. 6

slide28

Mass of the Neck

Present Illness

  • This 34 y/o male has found a nodule over right infra-auricular area for 5~6 years, which was painless and no special feeling. So, he didn’t pay attention about it. Recently he went to LDC for full mouth scaling, the LDC dentist noted this swelling. According to his statement, he felt it grew larger and tenderness recently. So, he come to our OPD for further evaluation and treatment.
slide29

Mass of the Neck

Personal History

  • Alcohol (-)
  • Betel quid (-)
  • Smoking (-)
  • Denied other special habits
slide30

Mass of the Neck

Past History

Past Medical History

  •  Denied any systemic disease
  •  Drug allergy (+) : unknown

Past Dental History

  •  OD
  •  Prosthesis
  •  Tooth Extraction
  •  Full mouth scaling
slide31

Mass of the Neck

Clinical Examination

Extra-oral

  • Fluctuation: __
  • Pain: __
  • Tenderness: +
  • Mobility: movable
  • Induration: __
  • Lymphadenopathy: __

Ref. 6

slide32

Mass of the Neck

CT Findings

Petrous effect

Ref. 6

slide33

Features Suggestive of Benignancy

  • Movable (except palate)
  • Unattached to skin or mucosa (except palate)
  • No ulceration of skin or mucosa
  • Slow growth
  • Long duration
  • No pain
  • No facial nerve palsy

Features Suggestive of Malignancy

  • Induration
  • Fixed to overlying skin or mucosa
  • Ulceration of skin or mucosa
  • Rapid growth; Growth spurt
  • Short duration
  • Pain, often severe
  • Facial nerve palsy

Ref. 6

infection or benign malignant

Mass of the Neck

Infection or Benign / Malignant
  • Pain (-)
  • Growing slowly (5~6 years)
  • Smooth surface
  • CT findings : demarcated margin
  • No other structure destruction

 Benign Tumor

working diagnoses

Mass of the Neck

Working Diagnoses
  • Pleomorphic Adenoma
  • Warthin’s Tumor
  • Basal Cell Adenoma
  • Oncocytoma
pleomorphic adenoma

Mass of the Neck

Pleomorphic Adenoma
  • 53% ~ 77% of parotid tumors
  • Painless, slow growing, firm mass
  • Facial palsy & pain are rare
  • Age: 30 ~ 50 y/o
  • Slight female predilection
warthin s tumor

Mass of the Neck

Warthin’s Tumor
  • Occurs almost exclusively in the

parotid gland

  • 5 % ~ 14 % of parotid tumors
  • Slow-growing, nodular mass
  • Firm to fluctuant to palpation
  • Bilateral occurrence (5-14%)
  • Age: older adults, 51-70 y/o
  • Associated with smoking
basal cell adenoma

Mass of the Neck

Basal Cell Adenoma
  • Parotid (75%)  1st , minor glands  2nd (esp.

upper lip, buccal mucosa)

  • Age: middle-aged、older adults、61~70 (most)
  • Sex predilection: female ( female : male = 2:1

in some study)

  • Slow growing, freely movable mass, similar to

pleomorphic adenoma

  • Most tumors are less than 3 cm in diameter
  • 1% of all salivary gland tumor
oncocytoma

Mass of the Neck

Oncocytoma
  • Painless, slow growing,
  • Firm mass rarely > 4cm
  • 80% in parotid gland
  • Older adults, 71~80 (peak)
  • Slight female predilection
  • Occurrence: < 1% of all salivary gland

tumor

clinical impression

Mass of the Neck

Clinical Impression
  • Pleomorphic Adenoma, right

parotid gland

slide42

Mass of the Neck

Excisional Biopsy

Ref. 6

slide45

Pleomorphic adenoma

Rt parotid gland

Mass of the Neck

HistopathologicalDiagnosis

Ref. 2

slide46

Mass of the Neck

Mass of specific location

Masses in median-paramedian region

Submental lymph nodes: enlargement

- Infection: lymphoid hyperplasia

: acute lymphadenitis

- metastatic cervical node

- lymphoma

Epidermoid and dermoid cyst

- Do not have tongue elevation

(重要)

Ref. 1

slide47

Mass of the Neck

Mass of specific location

Masses in median-paramedian region

Thyroid gland infection

-thyroiditis

Acute suppurative inflammation,

iodine

-Hasimoto’s disease

Autoimmune disease, sensitive to

its own thyroglobulin

Ref. 1

slide48

Mass of the Neck

Mass of specific location

Masses in median-paramedian region

Thyroglossal duct cyst

-Arise from remnants of embryonic

thyroglossal duct from tongue

base to sternum

-Upward thrust when protrude the tongue

-Most commonly occurs below hyoid bone

-Dome-shaped

(重要)

Ref. 1

slide49

Mass of the Neck

Mass of specific location

Masses in median-paramedian region

Riedel’s thyroiditis

-A fixed & hard mass

-Mimicking a malignancy

Thyroid neoplasm (within thyroid gland)

-Benign & malignant tumor

-Cyst

Ref. 1

slide50

Mass of the Neck

D.D. ofmasses in median-paramedian region

1. Thyroglossal duct cyst

2. Epidermoid/dermoid cyst

3. Submental lymphadenitis

4. Submental abscess

5. Thyroid gland tumor

6. Ectopic thyroid gland

Ref. 3

slide51

(Fig. below).

6. Ectopic thyroid gland

Mass of the Neck

Ref. 7

slide52

Mass of the Neck

Lateral region (low-level)

1. Intrathoracic goiter

2. Esophageal fibroma

3. Metastatic carcinoma

4. Sarcoidosis

Ref. 3

slide53

Mass of the Neck

Lateral region (high-level)

1. Salivary gland tumor

2. Sialadenitis

3. Carotid body tumor

4. Branchial cleft cyst (2nd arch)

5. Cystic hygroma

6. Neurofibroma

7. Fibroma

8. Hemangioma

9. Plunging ranula

10. Enlarged nodes

Ref. 3

slide54

Mass of the Neck

Cystic hygroma

-developmental benign cystic dilation of

lymphatic vein at variable ages after birth

-occur at any points in neck from skull base

down to mediastinum

-enlarges at an alarming rate causing

suffocation

-fluid aspirated from the mass froths

readily on agitation due to high fat content

lymph fluid

slide55

Mass of the Neck

A 26-year-old male presented with a 2-month history of a mildly painful, slow growing, nodular mass of the submental region. Extraoral examination revealed a 1.5 1.0-cm midline swelling of the submental region. The skin over the mass appeared normal. The mass was firm and slightly tender on palpation and appeared to be positioned within the submental space. Intraoral examination did not reveal any obvious pathologic findings and the nearby teeth showed no caries, periodontal disease, or mobility. The patient’s medical history was unremarkable.

Ref. 8

What is your differential diagnosis after studying this lecture?

slide56

Summaries

明白頸部腫脹之鑑別診斷原理,並知道其中的應用。