EXAMINATION OF HEAD AND NECK

SWELLINGSBy

Dr Eromosele Obehi

FORMAT• INTRODUCTION• CLASSIFICATION OF SWELLINGS OF

THE HEAD & NECK • EXAMINATION OF HEAD & NECK

SWELLINGS • CONCLUSION• REFERENCES

INTRODUCTION

A swelling is an enlargement or protuberance in the body. According to cause, it may be congenital, traumatic, inflammatory, neoplastic (wikipedia).

• Swellings can occur in any part of the body.• Assessment of swellings are basically invariable

irrespective of its location.• The principle for examination of all swellings remain the

same with slight variability with respect to its location.• The importance of examination of swellings cannot be

over emphasized; it is necessary for both diagnostic and prognostic purposes.

CLASSIFICATION OF HEAD AND NECK SWELLINGS

• Based on cause• 1. INFECTION• 2. NEOPLASM- BENIGN/MALIGNANT• 3. CYSTIC• 4. TRAUMA

CLASSIFICATION OF SWELLINGS IN THE HEAD &NECK

• Based on anatomical site1. LIP- Squamous Cell Carcinoma (SCC), angioedema, dento-alveolar abscess2. TONGUE- SCC, hemangioma, lymphangioma, neurofibromatosis, 3. PALATE- Benign/malignant salivary neoplasm, osteoma4. FLOOR OF MOUTH- Ranula, sublingual dermoid cyst5. GINGIVA/ALVEOLUS- Fibroma (epulis), fibrosarcoma, osteoma,

osteosarcoma6. JAWS- dento-alveolar abscess, osteomyelitis, ludwig’s angina dental cysts,

dentigerous cysts, odontogenic tumours, osteogenic sarcoma, burkitt’s lymphoma, metastasis, SCC (maxillary antrum)

7. SALIVARY GLANDS- bacterial/viral infection, duct obstruction (calculi), sialectasis, pleomorphic adenoma, adenoid cystic carcinoma, adenocarcinoma, sjogren’s syndrome

NECK SWELLINGSMIDLINE

CYSTIC SOLID

THYROGLOSSAL CYST ADENOMA OF THYROID ISTHMUS

SEBACEOUS CYST LYMPH NODE

SUBLINGUAL DERMOID CYST LIPOMA

CYSTIC SOLID

BRANCHIAL CYST LYMPH NODE

CYSTIC HYGROMA SUBMANDIBULAR SALIVARY GLAND SWELLING

SEBACEOUS CYST GOITRE

CAROTID BODY TUMOUR TUMOR

LIPOMA

STERNOCLEIDOMASTOID TUMUOR

LATERAL

EXAMINATION OF HEAD AND NECK SWELLINGS

• An important part of the examination is HISTORY TAKING. It is essential to ascertain

• When did the swelling appear/when was it first noticed? It is important to be precise with dates and terminology (example..)

• Whether it is changed in size since it was first noticed?• Whether there is any possible cause for the swelling i.e. trauma

etc• What are the symptoms of the swelling? It may be painful and

if it is, you must take a careful history of the pain. The characteristic feature of pain associated with acute infection is its throbbing nature. It may be disfiguring or interfere with movement, respiration and swallowing.

HISTORY OF PAIN

•Site- specific, indistinct/diffuse•Its character/nature - dull, sharp, throbbing•The severity- varying degrees. How much does it affect normal function?•Time and mode of onset- day/night (time interval between each event), insidiously/suddenly•Is it continuous or there are remissions?•Does it Radiate?-•Relieving/exacerbating factors

GENERAL PRINCIPLES OF EXAMINATION

LOOK (inspection), FEEL (palpation) TAP(percussion), auscultation.

LOCAL EXAMINATION

1. The exact anatomical location of the mass. • Skin subcutaneous tissue, muscle, tendon, nerve,

bone, blood vessels, lymph node or an organ. Failure to ascertain location will give an inaccurate diagnosis.

Deciding the exact anatomical location of any swelling or mass is probably the most important single step taken in examination of a swelling.

Contd..

2. Shape

3. Size

4. Surface- the surface of a mass may be smooth, rough, lobulated, irregular.

5. Color : this may be a helpful diagnostic sign. Reddening may suggest an inflammatory etiology while a bluish swelling which blanches on pressure is most probably a haemangioma.

6. Consistency- defined surgically as soft, as in the case of a lipoma, firm which is the consistency of a fibroma, cartilage hard as in pleomorphic adenoma, bony hard exemplified by an osteoma, rock hard as seen in malignant lymphatic nodes and rubbery hard as in Hodgkin’s lymphoma

Contd..

7. Edge: The edge of a swelling may be clearly defined, diffuse or fading into the surrounding tissues as in the case of inflammatory swellings

8. Single or multiple9. Is the lump tender or warm on palpation? Tenderness on

gentle palpation is a valuable physical sign, while it can be elicited with inflammatory lumps, neoplasm & cystic swellings are commonly painless except there’s 2° infection. The site of an acute inflammation is warmer than the adjoining areas.

Contd..

10. Are there signs of inflammation present? The classical signs of heat, redness, swelling and pain are indicative of either an inflammatory swelling or secondary infection in a non inflammatory mass.

11. Is the swelling attached to the skin? Attempt should be made to move the skin over the swelling to ascertain if the skin is tethered to it. The skin overlying an abscess may be fixed firmly to the inflammatory mass and a similar condition may occur with superficial malignancies. Of the benign lesions, sebaceous cyst is characteristically tethered to the skin by the punctum of the sebaceous gland from which it arises.

Contd..

12. Does the swelling arise from deeper structures.- can the overlying tissues move separately from it in any way? Getting the patient to tense adjacent muscles to see whether the lesion is attached to them.

13.Transillumination. The transilluminable swellings of the head and neck are cystic hygroma, hydrocephalus.

14. Is fluctuation present? Fluctuation is a valuable physical sign indicating the presence of fluid. It is elicited by placing the tips of 2 fingers on the swelling. When the pressure is applied to the mass with one finger, a transmitted upward impulse is felt with the other finger tip. For larger tumors 2 finger tips of one hand on the mass and then press between these 2 fingers with the tip of a finger of the other hand. The transmitted impulse will be felt with the finger tips of the opposite hand. A useful variation of this test can be carried out with fluid containing cysts of the jaws even when they are covered with an appreciable thickness of bone. Firm intermittent pressure with the thumb over the suspected cystic area in the buccal sulcus will produce a transmitted pulsation which can be detected by the finger tip of the other hand placed on the opposite side of the alveolar process in the palate or on the lingual side of the mandible.

Contd..

• 15 Is there pulsation? There are three types of pulsation which may occur in lumps

a. The mass may be pulsatile i.e. the entire mass pulsates. This is best exemplified by an aneurysm

b. Transmitted pulsation occurs when the mass rests on a large artery. When such a mass is palpated, an impulse is felt which is transmitted from the artery. Salivary adenomas in the palate may sometimes transmit pulsations of the greater palatine artery.

c. A mass lying deep in the tissues may displace an artery so that it lies superficially upon a the mass. On palpation the mass will appear to pulsate though the clinician is in fact palpating an artery

Contd..• 16. Pressure effects ona. Arteries: pressure on arteries is evidenced by diminution of the

pulse and in extreme cases by coldness of the dependent part and eventually by gangrene

b. Veins: pressure on veins may produce cyanosis and edema on the distal side of the vessel

c. Nerves: pressure on nerves may produce paraesthesia, anaesthesia, or paralysis etc

d. Neighboring organs: pressure may be exerted by a mass on any neighboring organ. In the head and neck 2 structures commonly affected in this way are the trachea and the esophagus, with resultant respiratory embarrassment and dysphagia.

Contd..

17. Are the associated lymph nodes enlarged? Whenever a lump or a mass is examined careful palpation of the associated lymph nodes must be carried out. This important step must never be omitted. In fact, in the clinical investigation of an oral lesion, it is prudent to examine the cervical nodes first before inspecting the mouth, to prevent missing this vital stage. The tender enlarged lymph nodes associated with inflammatory process are readily differentiated from the rock hard nodes of metastazing malignancy.

18. The general condition of the patient- massive swellings associated with cachexia of the patient are usually indicative of malignant neoplasms. Carcinoma of the head and neck does not commonly cause severe degeneration in the patients nutritional state until the terminal stages of the disease, unless the tumour affects the gastro intestinal tracts and mechanically interferes with ingestion and deglutition of food. Massive inflammatory swellings will produce a toxic effect on the patient. Such lesions occur only in the advanced stages of the disease.

CONCLUSION

• Evaluation and management are dependent on histologic type and extent of disease. The clinician should maintain a high index of suspicion when dealing with any swelling bearing in mind that it could be potentially malignant, and careful follow-up of patients with suspicious head and neck swelling is mandatory.

REFERENCES

• PRINCIPLES AND PRACTICES OF SURGERY INCLUDING PATHOLOGY IN THE TROPICS by E.A. Badoe et al

• AN OUTLINE OF ORAL SURGERY PART II by H.C. Killey et al

• Browse introduction to the symptoms and signs of surgical disease by Norman L. Browse et al

• www.wikepidia.com