頸部腫脹 Mass in the Neck 口腔診斷學 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, 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

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

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

Mass of the Neck Mass of nonspecific location 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

Mass of the Neck Mass of specific location ‘Which’ region will have ‘which’ lesions Mass of specific location Masses in submandibular region Masses in parotid region Masses in median-paramedian region Masses in lateral region Ref. 1 submandible parotid (para)median lateral

Mass of the Neck 1. Submental node 2. Submandibular node 3. Cranial jugular (deep cervical) node 4. Medial jugular 5. Caudal jugular 6. Dorsal jugular (superficial cervical) node along accessory n 7. Supraclavicular node 8. Prelaryngeal & paratracheal node 9. Retropharyngeal node 10. Parotid node 11. Buccal node 12. Retroauricular & occipital node 12 cervical lymph nodes Ref. 1

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

Mass of the Neck Ref. 10

Mass of the Neck Ref. 12

Mass of the Neck Ref. 12

Mass of the Neck Ref. 12

Mass of the Neck Ref. 12

Mass of the Neck Ref. 12

Mass of the Neck Ref. 12

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

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

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

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

Mass of the Neck Mass of specific location (觸診) Masses in parotid region Enlarged lymph 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

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

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) Ball in hand Refs. 2, 4, 5

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

Mass of the Neck Xerostomia Biparotid enlargement Dry eye Primary Sjogren syndrome Secondary Sjogren syndrome Conjunctivitis sicca Connective tissue disease (auto- immune disease) Ref. 7

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

Mass of the Neck Chief Complaint A swelling mass of R’t parotid area Ref. 6

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.

Mass of the Neck Personal History Alcohol (-) Betel quid (-) Smoking (-) Denied other special habits

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

Mass of the Neck Clinical Examination Extra-oral Fluctuation: __ Pain: __ Tenderness: + Mobility: movable Induration: __ Lymphadenopathy: __ Ref. 6

Mass of the Neck CT Findings Petrous effect Ref. 6

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

Mass of the Neck Working Diagnoses Pleomorphic Adenoma Warthin’s Tumor Basal Cell Adenoma Oncocytoma

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

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

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

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 Pleomorphic Adenoma, right parotid gland

Mass of the Neck Excisional Biopsy Ref. 6

Mass of the Neck Excisional Biopsy Ref. 6

Mass of the Neck Excisional Biopsy Ref. 6

Mass of the Neck Excisional Biopsy Ref. 6

Histopathological Diagnosis Mass of the Neck Histopathological Diagnosis Pleomorphic adenoma Rt parotid gland Ref. 2

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

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

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

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

Mass of the Neck D.D. of masses 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

Mass of the Neck 6. Ectopic thyroid gland (Fig. below). Ref. 7

Lateral region (low-level) Mass of the Neck Lateral region (low-level) 1. Intrathoracic goiter 2. Esophageal fibroma 3. Metastatic carcinoma 4. Sarcoidosis Ref. 3

Lateral region (high-level) 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

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

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?

Summaries 明白頸部腫脹之鑑別診斷原理，並知道其中的應用。