Diagnosis d & rsquo; a neck mass

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Goals :

  • Knowing recognize and analyze anterior and lateral cervical neck swelling.
  • Knowing direct the diagnosis to an earlier or lateral neck mass and know instead of ultrasound to help diagnose.

I- INTRODUCTION :

All constituents of the neck can cause cervical swelling, but lymphadenopathy is most often involved in the side of the neck swelling.
The cervical mass is a frequent reason for consultation.
The key is not to err in the event of malignant lymphadenopathy.

II- ANATOMICAL RECALL :

The neck lymph nodes are grouped in chains, connected together by lymphatic vessels, and arranged anatomically d & rsquo; a particular way, Le Cercle de Cuneo péricervical(submental lymph nodes, submandibular, parotidiens, mastoïdiens et occipitaux), triangle Rouviere (leading edge formed by the carotid-jugular chain, sleep posterior formed by the spinal channel and the base formed by the transverse supraclavicular chain) in addition to the previous channel and prélaryngée pretracheal.

III- POSITIVE DIAGNOSIS :

A- CLINICAL GUIDANCE :

Examination : Research:

– L & rsquo; age.
– The profession.
– Antecedents.
– Toxic habits.
– The date of onset.
– Accompanying signs (dysphagie, dysphonie, pain, etc.)

Cervical examination :

  • L’inspection: Appreciate the location of the weight and condition of the skin facing (healthy or inflammatory.)
  • palpation: capital time, appreciates the mass characteristics (seat, cut, consistency, sensitivity and mobility compared with the more superficial and deep.)
  • The rest of the & rsquo; ENT examination (anterior rhinoscopy, otoscopy and oropharyngeal examination) can guide diagnosis.

General review : Find more lymphadenopathy, hepato and splenomegaly.

B- DIAGNOSTIC PARACLINIQUE :

Biology report :

FNS.
VS.
TST.
infectious serology. They are not all systematic, but some of them are requested appropriately depending on the context and clinical orientation

radiological assessment :

  1. Chest radiograph Front.
  2. Radiography of the neck front / profile.
  3. cervical Ultrasound : an easy exam, fast, unaggressive and reproducible. It provides information on the liquid or solid mass, allowing the differential diagnosis of cystic swelling (with liquid contents), lipome (often evocative appearance laminated hyperechoic) solid or swelling. It is possible to perform ultrasound-guided fine needle punctures the sighting cytological.
  4. Scanner : is useful in case of diagnostic doubt between lymphadenopathy, nerve tumor or tumor salivary (parotid or submaxillary).
  5. cervical MRI : is an important aid in the diagnosis of tumors and salivary nerve tumors. It outperforms the scanner to study the reports of lymphadenopathy with neighboring structures.

Cytological assessment :

  1. FNA in & rsquo; fine needle : can guide diagnosis, in particular in the case of metastatic lymph node carcinoma of the upper aerodigestive tract or papillary thyroid carcinoma. Elle in Permet de les tumores fluctuantes préciser the character of the collection liquidienne, to a bacteriological examination and cytological.
  2. Cervicotomy Explorer with pathological study.

IV- ETIOLOGICAL DIAGNOSIS :

It is guided by 4 criteria :

  • The patient's age will be decisive, tumor pathology differs between adults and children
  • The topography of the swelling goes towards the various diagnoses
  • The inflammatory nature
  • Consistency

MASSES GANGLION :

1- infectious causes :

a- Tuberculosis :

Most of the time, it is oral or pharyngeal primary infection unnoticed ; lymphadenopathy is often unique, rapidly evolving towards softening and fistulisation. It is not rarely associated with other tuberculous localizations.

The IDR is strongly positive.

FNA found most often a pus amicrobien : highlighting acid bacilli- alcohol-fast after Ziehl Neelson coloring is rare because they are very few.

Koch bacilli seeking (BK) PCR can enable rapid diagnosis but it is expensive.

Classical culture on Lowenstein requires two to three months for the identification of Mycobacterium tuberculosis and other mycobacterial species.

The treatment : is medical with antibiotics quad for a year. The association with corticosteroids may be useful for a few weeks. Surgical treatment should be reserved for failures of medical treatment.

b- La MNI :

The diagnosis is oriented by the clinic (concept of contagion, l & rsquo; angina or pseudomembranous erythematous pulpy, l & rsquo; asthenia, l’hépato-splénomégalie) la FNS (leukocytosis with lymphocytosis) and confirmed by the MNI-Test.

c- toxoplasmosis :

Accompanied most often multiple cervical lymphadenopathy, posterior and / or axillary. Associated signs are nonspecific : fleeting rash, low-grade fever, asthenia. The diagnosis is based on serology (increase in IgG over two levies 15 days & rsquo; interval). The lack of treatment is the rule.

d- The cat-scratch disease or benign inoculation lymphoréticulocytose :

Often accompanied by soft bulky lymphadenopathy, progressing to the fistulisation, appearing in the drainage area of ​​a cat scratch.
The diagnosis is usually serological.

e- rubella :

Comes with lymphadenopathy often multiple, occipitales. These usually precede the enanthem, himself inconstant, et persistent 2 at 3 month. Serology confirmed the diagnosis (increase in IgG over two levies 15 days & rsquo; interval).
Treatment is symptomatic.

f- syphilis :

g- HIV :

h- the tularémie :

2- Inflammatory causes :

a- the sarcoïdose : The diagnosis is oriented by the clinic (l’age, young adult, lymphadenopathy affecting several territories), VS (accelerated), the téléthorax (mediastinal lymph nodes performing the & rsquo; polycyclic picture) and confirmed by the & rsquo; anat-path study (epithelioid granuloma giant cell.)

b- Systemic lupus erythematosus.

c- Rheumatoid arthritis.

3- metastatic causes :

The diagnosis is oriented by the clinic (hard lymphadenopathy, cold and without periadenitis), primitive pole can be oriented by the seat of the mass.

4- Blood causes :

  1. The disease d & rsquo; Hodgkin: The diagnosis is confirmed by the & rsquo; Anatomical study-path (Sternberg cells.)
  2. The malignant non-Hodgkin's lymphoma (LMNH.)
  3. leukemias.

CAUSES GLANDULAIRES :

  1. Salivary tumors: The diagnosis is oriented by the clinic (mass seat), l & rsquo; Sialography and ultrasound and confirmed by the & rsquo; anat-path study.
  2. The Sialolithiasis: The diagnosis is oriented by the clinic (Saliva and salivary colic hernia) and confirmed by cervical radiograph (calculation radiopaque) and & rsquo; ultrasound or Sialography (calculating radio-transparent.)
  3. Thyroid tumors: The diagnosis is oriented by the clinic (prior basicervical seat), the dosage of T3 and T4, l & rsquo; sonography and scintigraphy and confirmed by FNA.

CONGENITAL KYSTS :

  1. The thyroglossal duct cyst: The diagnosis is oriented by the clinic (extra mass median or sub-hyoid) and confirmed by the & rsquo; ultrasound and fine needle aspiration.
  2. The amygdala cyst: The diagnosis is oriented by the clinic (high latero-neck mass) and confirmed by the & rsquo; ultrasound.

VASCULAR TUMORS :

The diagnosis is oriented by the clinic (beating mass with Thrille to & rsquo; auscultation) and confirmed by the & rsquo; Doppler and & rsquo; arteriography.

  1. L & rsquo; carotid aneurysm.
  2. The bulb carotid atheromatous.
  3. The tumor jugular glomus.

NERVE TUMORS :

  1. neuroma.
  2. Le Schwanome.
  3. the paraganglioma: Often diagnosed intraoperatively.

V- DIFFERENTIAL DIAGNOSIS :

It must eliminate false neck swellings that are anatomical traps :

  • The transverse process of the atlas
  • The projection of the tuber Chassaignac (C6)
  • The great horn of the hyoid bone
  • The bulb carotid atheromatous
  • Ptosis submandibular gland

WE- CONCLUSION :

The diagnosis of a neck mass is made by the clinic, cytology and imaging nerve tumors or vascular. However, in rare situations, the histological diagnosis is pending. Then the indication of the explorer cervicotomy with pathological examination extemporaneous.