Paper on Swelling in the Neck

Hampton, Patricia A&P II 01/17/13

Dr. Hackworth BIO 202 9:30

Problem: The purpose of this investigation is to outline strategies for assessments of neck swellings and management of more common swellings encountered in young children.

Introduction: Swellings of the neck are a common diagnostic challenge for physicians. A basic understanding of the anatomy of neck structures and a systematic way would enable a correct diagnosis in a quick and safe way. Familiarity with pathology and a thorough examination technique will allow for a working diagnosis on occasion.

Hypothesis: This study will ascertain the shape and size of swelling in the neck in relationship to surrounding tissues such as skin, muscles, trachea and hyoid bone are factors in determining the arrival of a sensible diagnosis in young children.

Research: Children are likely to present a short history of either enlarged tender lymph nodes, suggesting and infective or inflammatory process, or multiple small non-tender nodes, suggesting a viral infection. Long-standing cystic swellings in children suggest a congenital problem, possibly cystic hygroma. Thyroid swellings in children are uncommon, but 50% of them are malignant when they do occur. Other common clinical conditions in adolescents include:

• Thyroglossal cyst, presenting as a painless swelling at or below the level of the hyoid bone, which elevates on tongue protussion

• Branchial cyst, presenting as the anterior border of the sternomastoid muscle below the jaw, there is usually rapid painless development of the swelling although secondary infection and inflammation may occur

• Plunging ranula, a cystic swelling in the submandibular region due to extravasation through the mylohyoid muscle of mucoid saliva from a disrupted sublingual gland in the floor of the mouth.

Adolescents can also present with acute inflammatory lymphadenopathy in the jugulodigastric region and occasionally also in the posterior triangle. Glandular fever and viral conditions should be considered. The presence of multiple enlarged lymph nodes is more suggestive of infection. Adolescents, however, can develop lymphomas, particularly Hodgkin’s disease and prominent lymph nodes. Those larger than 2 cm should be evaluated to exclude malignancy, especially where the history suggests that there has been progressive slow enlargement. Skin cancers are rare in children and uncommon in adolescents.

The jugulodiastric lymph node is commonly enlarged in both inflammatory and malignant conditions.Children with tonsillitis, young adults with glandular fever or Hodgkin’s disease and middleaged adults with cancers of the oral cavity and oropharynx can all present with lymphadenopathy at this site. The lymph nodes are most commonly involved in viral infections in children. A solitary lump, low in the neck, deep to the sternomastoid muscle in the supraclavicular fossa is likely to be a metastasis from a primary cancer below the clavicles that is the lung, the oesophagus, the stomach or the pancreas.

Procedure: A thorough history is essential for important clues to the origin of the swelling. Three key areas to the history are:

• History and symptoms of the swelling, including pain, duration and size increase or decrease

• Head and neck symptoms, such as throat pain, otalgia, dysphagia and voice changes

• Symptoms of systemic illness, such as fever, malaise, weight loss and night sweats

After a thorough examination, one should be able to answer four initial questions:

• Is there more than one swelling?

• Where is it? (anterior/posterior compartment of the neck )

• Is it solid or cystic?

• Does it move when swallowing? (This indicates it is deep to the pretracheal fascia and likely to be thyroid.)

Once the examination is completed a plan of action is determined based on data.

• Fine –needle biopsy: This is the single most important test in the evaluation of neck lumps. It is necessary to carry out needle biopsy of tender lymph nodes in children. It is the best initial investigation of the thyroid swellings. Metastic malignancy can be diagnosed with a high degree of accuracy. Reactive lymphadenopathy can be distinguished from lymphoma on needle biopsy.

• Ultrasound: Ultrasound is not particularly useful in the evaluation of neck lumps. It can differentiate between solid and cystic masses and can indicate whether or not there are multiple enlarged lymph nodes or the presence of multiple nodules in the thyroid gland. Ultrasound rarely assists in clarifying the diagnosis.

• Computed Tomography: CT scans are far more helpful than ultrasound in assisting with diagnosis of neck swellings, especially when they are larger than 2 cm. Computed tomography scanning can provide an idea of the consistency of a lump along with its size and anatomical relations.

• Excision biopsy: If a diagnosis cannot be confirmed on fine-needle aspiration biopsy, an excision biopsy may be necessary to confirm or exclude malignancy. Care should be taken not to spill tissue or break up a lymph node in the course of biopsy because malignant cells may be implanted into the surrounding tissue.

• Chest X-ray: Chest radiology is important in adolescents, when lymphoma is the possibility. It demonstrates mediastinal widening or primary or secondary lung neoplasms.

Conclusion: The hypothesis is supported by the research and the procedures. There are many reasons a swelling in the neck of a young child. However, before an accurate diagnosis can be made steps should be taken to make an educated decision. The steps listed in the procedure will provide for accurate diagnosis determination. Incorrect information presented in the patient history or incorrect reading of lab reports could cause a wrong diagnosis made by the doctor. This investigation has provided me with the different types of interventions available for diagnosis of swellings in the neck and the one that will provide the most accurate results for determining a diagnosis.

http://www.surgwiki.com/wiki/Neck_swellings