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學 習 目 標學 習 目 標
1. 明白頸部腫脹之鑑別診斷
1. Wood, Goaz. Differential Diagnosis of Oral Lesions. Mosby Publisher, 3rd Edition, Chapter 29, 634-5.
2. 自購網路資源: super_toolcool 3. 網路資源 (anonymous)4. 口腔影像的臨床診斷 , 2nd edition, Chapter 12, p.2835. Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 31, p.
403-4146. Kaohsiung Medical University Oral Pathology7. Crispian Scully. Handbook of oral disease - diagnosis and management.
Martin Dunitz Publisher, 1st ed. p. 267-8, 3768. Yeshwant B. Rawal, Carl M. Allen, John R. Kalmar. A nodular submental mass. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007;104:734-79. 彼得 史彼爾人 . 漢聲雜誌 民國 86, 5 月 , p. 810. Carlson ER et al. Neck dissections for oral/head and neck cancer:1906-2006. J
Oral Maxillofac Surg 2006;64:4-1111. Misra S et al. Management of gingivobuccal complex cancer. Ann R Coll Surg
Engl 2008;90:546-5312. WoolgarJ et al. Neck dissections: A practical guide for the reporting
histopathologist. Current Diag Pathol 2007;13:499-511
References:References:
參考資料
Mass of the NeckMass of the Neck
Contains many vitalanatomic structures& diverse tissue types
Contains many vitalanatomic structures& diverse tissue types
Diverse and variedpathological lesions
Diverse and variedpathological lesions
Examination of neckshould be performedin patient evaluation
Examination of neckshould be performedin patient evaluation
Constitutes a small %of the total body area
Constitutes a small %of the total body area
Refs. 2, 3, 9
Mass of the NeckMass of the Neck
A rule of thumb for the duration A rule of thumb for the duration of the massof the mass
Day Day (7 days):(7 days): Inflammatory lesions Inflammatory lesions
Month Month (7 months):(7 months): Neoplasm Neoplasm
Year Year (7 years):(7 years): Congenital lesions Congenital lesions
Mass of the NeckMass 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
Certain lesions are found in discrete anatomic locations A knowledge of those lesions associated with specific regions in the
neck is useful Mass of nonspecific location Skin & subcutaneous tissues within the neck - mobile skin - cervical fascia
Mass of nonspecific location Skin & subcutaneous tissues within the neck - mobile skin - cervical fascia
Regional approach
Ref. 2
Mass of the NeckMass of the Neck
Mass of specific location Masses in submandibular region Masses in parotid region Masses in median-paramedian region Masses in lateral region
Mass of specific location Masses in submandibular region Masses in parotid region Masses in median-paramedian region Masses in lateral region
submandible parotid (para)median lateral
‘Which’ region will have ‘which’ lesions
Ref. 1
Mass of the NeckMass of the Neck1. Submental node
2. Submandibular node3. Cranial jugular (deep cervical) node4. Medial jugular (deep cervical) node5. Caudal jugular (deep cervical) node6. Dorsal jugular (superficial cervical) node along accessory n7. Supraclavicular node8. Prelaryngeal & paratracheal node
9. Retropharyngeal node
10. Parotid node
11. Buccal node
12. Retroauricular & occipital node12 cervical lymph nodes Ref. 1
Mass of the NeckMass of the Neck
Levels 1-III:Sentinel LN oforal cancer(1st meta LNs)
Refs. 10, 11
Levels I-V: Basis ofthe nomenclature for the classification of neck dissections for oral/head & neck cancers
Ref. 10
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass of the Neck
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass of the Neck
Ref. 12
Mass of the NeckMass 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
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 NeckMass 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
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 NeckMass of the Neck
Find the origin: - Infection: lymphoid hyperplasia : acute lymphadenitisInfection source- pericoronitis (third molar) - infected cyst - metastatic cervical nodePrimary tumor – oral SCC, NPC, others - lymphoma (solitary/multiple; uni/bilateral)History, biopsy, imaging examination
Find the origin: - Infection: lymphoid hyperplasia : acute lymphadenitisInfection source- pericoronitis (third molar) - infected cyst - metastatic cervical nodePrimary tumor – oral SCC, NPC, others - lymphoma (solitary/multiple; uni/bilateral)History, biopsy, imaging examination
Ref. 2
Mass of the NeckMass 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)
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 NeckMass 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
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 NeckMass of the Neck
Locate the origin: - Infection: lymphoid hyperplasia : acute lymphadenitisInfection source- infected cyst (congenital preauricular cyst, sebaceous cyst) - metastatic parotid nodePrimary tumor – oral SCC, NPC, others - lymphoma (solitary/multiple; uni/bilateral)Biopsy, imaging examination
Locate the origin: - Infection: lymphoid hyperplasia : acute lymphadenitisInfection source- infected cyst (congenital preauricular cyst, sebaceous cyst) - metastatic parotid nodePrimary tumor – oral SCC, NPC, others - lymphoma (solitary/multiple; uni/bilateral)Biopsy, imaging examination
Ref. 2
Mass of the NeckMass 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)
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 handRefs. 2, 4, 5
Mass of the NeckMass 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 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 NeckMass of the Neck
Biparotid enlargement
Xerostomia
Dry eye
Primary Sjogren syndrome
Secondary Sjogren syndrome
Xerostomia Conjunctivitissicca
Connective tissuedisease (auto-immune disease)
Ref. 7
Mass of the NeckMass 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 NeckMass of the Neck
Chief Complaint A swelling mass of R’t parotid area
Ref. 6
Mass of the NeckMass of the Neck
Present IllnessThis 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 NeckMass of the Neck
Personal History
Alcohol (-) Betel quid (-) Smoking (-) Denied other special habits
Mass of the NeckMass 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 NeckMass of the Neck
Clinical Examination
Fluctuation: __
Pain: __
Tenderness: + Mobility: movable Induration: __
Lymphadenopathy: __
Extra-oral
Ref. 6
Mass of the NeckMass of the Neck
CT Findings
Petrous effectRef. 6
Features Suggestive of Benignancy1.Movable (except palate)2.Unattached to skin or mucosa (except palate)3.No ulceration of skin or mucosa4.Slow growth5.Long duration6.No pain7.No facial nerve palsy
Features Suggestive of Malignancy1. Induration2.Fixed to overlying skin or mucosa3.Ulceration of skin or mucosa4.Rapid growth; Growth spurt5.Short duration6.Pain, often severe7.Facial nerve palsy
Ref. 6
Infection or Benign / Malignant
Pain (-) Growing slowly (5~6 years) Smooth surface CT findings : demarcated margin No other structure destruction
Mass of the NeckMass of the Neck
Benign Tumor
Working Diagnoses
Pleomorphic Adenoma Warthin’s Tumor Basal Cell Adenoma Oncocytoma
Mass of the NeckMass of the Neck
Mass of the NeckMass 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 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 NeckMass of the Neck
Mass of the NeckMass 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 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
Mass of the NeckMass of the Neck
Pleomorphic Adenoma, right
parotid gland
Clinical Impression
Mass of the NeckMass of the Neck
Mass of the NeckMass of the Neck
Excisional Biopsy
Ref. 6
Mass of the NeckMass of the Neck
Excisional Biopsy
Ref. 6
Mass of the NeckMass of the Neck
Excisional Biopsy
Ref. 6
Mass of the NeckMass of the Neck
Excisional Biopsy
Ref. 6
Pleomorphic adenoma
Rt parotid gland
Mass of the NeckMass of the NeckHistopathological
Diagnosis
Ref. 2
Mass of the NeckMass 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
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
Ref. 1
( 重要 )
Mass of the NeckMass 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
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 NeckMass 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
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 NeckMass 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
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 NeckMass of the Neck
D.D. of masses in median-paramedian region D.D. of masses in median-paramedian region
6. Ectopic thyroid gland
1. Thyroglossal duct cyst
2. Epidermoid/dermoid cyst
3. Submental lymphadenitis
4. Submental abscess
5. Thyroid gland tumor
Ref. 3
Mass of the NeckMass of the Neck
6. Ectopic thyroid gland
(Fig. below).
Ref. 7
Mass of the NeckMass of the Neck
1. Intrathoracic goiter
2. Esophageal fibroma
4. Sarcoidosis
3. Metastatic carcinoma
Lateral region (low-level)Lateral region (low-level)
Ref. 3
Mass of the NeckMass of the Neck
3. Carotid body tumor
4. Branchial cleft cyst (2nd arch)
5. Cystic hygroma
6. Neurofibroma
2. Sialadenitis
8. Hemangioma
1. Salivary gland tumor
7. Fibroma
9. Plunging ranula10. Enlarged nodes
Lateral region (high-level)Lateral region (high-level)
Ref. 3
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
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 NeckMass 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.
What is your differential diagnosis after studying this lecture?Ref. 8
Mass of the NeckMass of the Neck
SummariesSummaries明白頸部腫脹之鑑別診
斷原理,並知道其中的應用。