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.. ‫ بسـم الله الرحمـن الرحيـم‬..

Today we are going to talk about a practical thing u do it


almost every time u see a patient or examine him .

The main topic today is about cervical lymphadenopathy


& lymph node examination .

So 1 .. 2 .. 3 .. let’s go .. ;D

As u know the neck is divided in to 2 triangles (anterior &


posterior ) by the sternomastoid muscle( this muscle is
attached from one end to the mastoid and the other end to
the clavicle) to determine whether an abnormality is in the
ant. or post. triangle, the sternomastoid muscle should be
rendered tense by asking the patient to depress the chin
against resistance .

“ U should know the anatomy in order to examine your


patient correctly “
Post. belly Ant. belly
of of
digastric digastric

Sup. belly
of
omohyioid

Sternoclido
Inf. belly of mastoid M.
omohyioid
M.
Lymph node anatomy:
Lymph nodes are divided into two groups:
1) Circular: which also divided into two subgroups:
A- Outer: which includes: submental,
submandibular,facial, postauricular (mastoid),
parotid (preauricular), occipital.
B- Inner: which includes: retropharyngeal,
pretracheal, paratrachyeal.
1) Cervical: which includes: superficial cervical, deep
cervical, jugulodigastric, jugulo-omohyoid.

Lymph node examination :


1.
Cervical lymph node examination:
It’s located at the anterior border of the
sternocleidomastoid muscle and devided into
superior , middle & inferior groups .

Normally, u don’t feel any nodes. If u do palpate


some nodes then they should be soft , pea sized , non
tender & freely mobile .

“ soft = girl “ &” hard = guy” as the doctor explained to


Khalid al 7arbe .. 
And now .. how to examine the lymph node in the
neck ..?
First of all u have to explain to the patient what are u
going to do , then…..
Stand behind or to the side of the patient & palpate the
nodes with the pulp of your finger gently by rolling the
tissue against something hard which is the
transverse process of the vertebrae in an upward
direction (according to the cervical lymph node) or the
muscle it self . U really need to be gentle coz
sometimes the lymph nodes are tender & the pressure
u apply on them is harming the patient .
U can examine them unilaterlay, each side alone, or
both sides at the same time “bimanual” .
The only node that should be palpated alone is the
tonsillar node .

2. And now how to examine the submandibular


lymp node .. ?

U place the tip of your fingers in the midline & roll


the tissue against the lower border of the mandible
which is the hard surface there , and sure u can do it
bimanually . Bimanual palpation of the floor of the
mouth should additionally be done if the submental &
submandibular nodes are enlarged . using gloved
hands, support the floor of the mouth firmly with your
left palm under the chin . place the fingers of your right
hand inside the mouth & feel the floor & sides of the
mouth for any enlargement or swelling . Note the shape
, size , mobility &
tenderness .

NOTE: Some times it’s difficult to differentiate between


inflamed submandibular gland and submandibular
lymph node coz if the gland is inflamed or enlarged the
lymph node will be enlarged & inflamed as well ..
3. Supraclavicular lymph node :
Palpated by standing infront of the patient, have
the patient flex the neck toward the chest, then feel
behind the clavicle adjacent to the suprasternal
notch on both sides simultaneously with the pulp of
your fingers. U will begin palpation as the patient
take a deep breath, because deep breathing brings
to the surface any enlarged nodes, if present, tumor
involving the lung, breast, upper abdomen or liquid
tumor can enlarge the supraclavicular nodes .
“ examination of the lymph node is a simple
procedure but it’s a valuable one “

Important notes:
• If a node is palpable, then u should record the:
1) Site.
2) Size.
3) Texture: soft-infective, rubbery hard-possible
hodgkin’s , stony hard-secondary carcinoma.
4) Tenderness to palpation-infection.
5) Fixation to surrounding tissue-may suggest metastatic
tumor.
6) Coalescence-TB.
7) Number of nodes: multiple-glandular fever or leukemia.
To make life easy, remember this: SSTTFCN, or 2S2TFCN.
• Palpable node charactistics:
1) Acute infection: large, soft, painful, mobile, discrete,
rapid onset.
2) Chronic infection: large, firm, less tender, mobile.
3) Lymphoma: rubbery hard, matted, painless, multiple.
4) Metastatic cancer: stony hard, fixed to underlying
tissue,painless.

Lumps & swellings:


In general speaking the management of any patient
involves history taking , examination , investigation ,
diagnosis & treatment planning .

One of the important thing u should all know is how to take a


history of a lump or a swelling . there is a standard
procedure for taking a history of a lump , swelling , pain &
ulcer . by asking the patient about :

- Onset : when did it start .?


- Any change in size or shape “consistency , surface
,tenderness/pain“ ..?

- Is it painless or associated with pain ..?

- Who noticed the swelling , the patient him self or some


one else ..?

- Is there any swelling in the same side or other sites ..?

- Does the lump ever disappear ..?

- What does the patient think caused the lump ..?

- Any medical problems contributing to it, such as “drug


history, operation, allergy, social history & habit “.

The main steps of examination are : inspection ,


palpation , percussion , auscultation ..

When you look to a swelling or an enlarged lymph


node what can you see ..?
– The site of the swelling , size , color , surface and
shape of it .

If u see a swelling in the neck what is your differential


diagnosis ..?
When you arrange your differential diagnosis u have to
start with the most common things first and go down to
the least common things “ most common things
happen most commonly “ . as if u see a swelling in the
neck have a chances to be a carotid body tumor are
very slim but the chances to be an infection are very
high .
So swellings in the neck could be :-
1. Lymphatic swelling . 4.
Salivary gland conditions .
2. Cystic swelling . 5.
Thyroid gland conditions .
3. Other swelling . 6. Tumors
.

And now we gonna focus on lymphatic swellings which


we call them “cervical lymph adenopathy and
enlarged lymph nodes “ .

It may be caused by :-

1. Infection :
The signs of infection are redness , hotness & pain
.
When you see the area is red , warm & painful the
more suggestive cause is inflammation or infection,
but if it was covered by normal skin it’s not likely to
be an infection .

The infection may be caused by :


A. Viral :
– viral respiratory infection (upper respiratory tract
infection as influenza) .
– Infectious mononucleosis .
– Measles (rubella) .
– Herpetic stomatitis .
– HIV infection .
– Herpes simplex 1 in oral mucosa which is a subclinical
infection not causing clear symptoms so the patient
won’t seek for medical help .
– Herpes zoster which happens unilaterally in one side
cause it follow the division of the main branch of the
trigeminal nerve .

A.Bacterial :
– Face , mouth . - tonsils , nose ,
sinuses .
– Scalp . - tuberculosis .
– Syphilis . - cat scratch disease
.
– Brucellosis . - lyme disease .

• tuberculosis : used to be a killer disease (endemic),


come to an area and kills a huge number of ppl . but
because of medicine it disappears , and now it’s
emerging (becoming a serious health problem) in
certain part of the world and in certain group of
patients particularly the immunocompromised➢ Redness(or blackness if u
patients . want)
➢ Hotness (ofcaurse can’t be
seen)
C. ➢ Pain (also not seen)
parasites :

Toxoplasmosis .
** dental source of infection **

**ludwige’s angina: an
infection involving the submandibular,submental
& sublingual spaces bilaterally . it can endanger the
patency of the air ways & considered as a medical
emergency & life threatening .**

2 . unknown :
Some times it’s not possible to know the cause , such
as in Mucotaneous lymph nodes syndrome ( kawasaki’s
disease ) why it’s causing lymph node enlargement is
not exactly known .

3 . neoplasm : primary : hodgkin’s & non-hodgkin’s


lymphoma .
Leukemia .
Secondary : carcinoma .
**cystic hygroma : malformation involving lymphatic
system & usually treated by medical treatment &
surgical excision **

1. Others : connective tissue disease .


Sarcoidosis .
Some immune deficiencies .

Now we gonna copy paste from the handouts coz the dr.
didn’t explain the rest .. sorry 

1. Cystic swelling of the neck :-


Lateral neck :
midline :
Branchial cyst (lympho epithelial )
thyroglossal cyst
Epidermal cyst
dermoid cyst
Cystic hygroma
plunging ranula
Sebaceous cyst ( hear bearing area )

2. Salivary gland condition :-


Infection : acute / chronic sialadenitis
Inflammatory / autoimmune : sjorgen’s syndrome
Neoplasm : pleomorphic adenoma

3. Thyroid :-
Thyroid gland
Thyroid gland enlargement : Hashimota’s disease
Goiter
Tumor
4. Tumors :-
Lipoma sternomastoid
tumor
Carotid body tumor branchial carcinoma
Neurofibromas

5. Others :-
Aneurysm : e.g. common carotid & subclavian
Cervical rib
Pharyngeal pouch

Dermoid and epidermoid cysts:


– Dermoid:
Relatively uncommon developmental lesion
originate in the midline of the floor of the
mouth above the mylohyoid muscle
– Clinical features:
Produce swelling in the floor of the mouth &
neck .
– Pathogenesis :
Presumed to arise from the encalvement of
epithelium in the midline as a result of deranged
fusion of the mandibular & hyoid branchial arches to
be designed as dermoid :
Skin appendages such as :
Hair follicles
Sebaceous glands
Sweat glands
– Erector pili muscles must be identified in the wall of the
cyst
Epidermoid cyst :
In the absence of skin appendages then called as:
epidermoid cyst

**Epidermoid cyst occurring elsewhere in the oral soft


tissues is acquired rather than developmental lesions .
They arise as a result of implantation of epithelium into
deeper tissues , with subsequent cystic change &
expansion .
– Treatment :
Enucleation.
Recurrence rare.

Branchial cyst ( lymphoepithelial


cyst ) :
– Majority occurs deep to sternomastoid or along its
anterior border at the level of the angle of the
mandible.
– Histologically :
The cyst is lined by stratified squamous epithelium
and it’s wall contain well organized lymphoid tissues.
– Pathogenesis :
Uncertain.
Classical explanation is that they are derived from
remnants of the branchial arches or pharyngeal pouch
has been disputed, and it is likely that most arise from
epithelium, probably salivary origin, that become
entrapped by
lymphoid
tissues.
– Treatment :
Excision.
Thyroglossal cyst :
– Developmental lesion.
– Derived from residues of the embryonic
thyroglossal duct.
– Thyroglossal tract extends from foramen caecum on
the tongue to the thyroid gland.
– Most thyroglossal cyst arise in the region of the hyoid
bone.
Intra-oral cyst , in the midline of tongue or floor of
mouth are rare.
– It is a midline swelling except in region of thyroid
gland where it might be pushed to one side, usually to
the left .
– Moves on swallowing .
– Moves upwards when tongue is protruded .
– Treatment :
Excision.
Cystic hygroma :
– Lymphangiomatous malformation which occurs rarely
in the development of the lymphatic system .
– Most frequently affects the head and particularly
neck region .
– Most are detected at birth .
– It presents as large , fluctuant swelling .
– They may extend to involve the base of tongue , floor of
mouth , less commonly buccal mucosa .
Translucency : because cystic hygroma is close to the
skin and contain clear fluid , their distinctive physical
sign is a brilliant translucence .
– Treatment :
Observation as spontaneous regression occasionally
occur without any treatment.
• Injection of sclerosing agent.
• Repeated aspiration.
• Incision & drainage.
• Radiotherapy.
• Intra-lesional injection of triamcinolone.
• Surgical excision ( treatment of choice ).
There is a picture for cystic hygroma
before….

The End ..
‫‪Done by :‬‬
‫‪Jumana Shamsah‬‬

‫&‬

‫‪Jumana Hassan‬‬

‫‪And Now to the most important part of the lec. Which is‬‬
‫الهــــــداءات‬

‫طبعـا أول النـاس وأغـلهم زوووز السـايب وسنـاءووو القديـمـي‬

‫والله من غيـــركم حيــاتنا سلطـــه‬

‫‪‬‬

‫حبيبي ورفيقي ابراهــيم حسـن ‪ ..‬وصديقتي الغالـيه نـداء نصـار مبروكـ التخرج والخطبـه‬
‫‪..‬‬

‫‪ ..‬ورفيقة الدرب ‪ ..‬سوسن الهـزاع‬

‫‪‬‬

‫واحلى اهداء لحلى قروب‬

‫‪A1‬‬
‫محمـد شعبـان "الخييير كله" ‪ ..‬أميـن مدلج "صديقي الصدوق" ‪ ..‬باسل رزق "انت اللي‬
‫فاهمني"‪ ..‬همام حروب "بلش تسرق القلم" ‪ ..‬عبدالله القحطاني وأحمدوو الجهني "وين‬
‫الجرين ستك " ‪ ..‬طلل "سلمه" ‪ ..‬عبدالرحمن "دحــوم" ‪ ..‬الحاج عمـار ‪ ..‬مروه ال‬
‫صفوان ‪ ..‬نور الرحمون ‪ ..‬محمد رمضان ‪ ..‬ابراهيم عواوده‬

‫منورييييين دايمـــا‬

‫‪ :‬والى احسن النــاس‬

‫ربى ابوريمه "احلى بنوته" ‪ ..‬اياس "ياااا الله ما اكذبك" ‪ ..‬عبدالله عوضي "يسلموو‬
‫‪" ..‬كثييير" ‪ ..‬شهد "نسمة هوا‬

‫‪" ..‬رونزيتا "الليدي" ‪ ..‬شيرين "وأتقـلب" ‪ ..‬محسن المحروقي ‪ ..‬ايمان "بل راس‬

‫امل العمري "احلى شال" ‪ ..‬مجد الصيدلي "أحلى رووح" ‪ ..‬لؤي قزقز"دي جي ريمكس‬
‫الرحالة الصغير" ‪ ..‬ميمنه الرشدان وأسيل ‪ ..‬ابو الوليــد ‪ ..‬صــالح اليافعي" بون وي" ‪..‬‬
‫علي الثالث ‪ ..‬عمــاد ‪ ..‬أدهم‬ ‫‪ ..‬رشيدان "ولتزعل لك احلى فطور" ‪..‬‬

‫معاذ ابو هديه ‪ ..‬تيــنا ‪ ..‬ميسـم ‪ ..‬ليث ‪ ..‬اسماء ‪ ..‬لمياء وفاطمه عليان ‪ ..‬نور كريشان ‪..‬‬
‫‪ ..‬اسراء شطاره "أحسن بارتنر" ‪ ..‬فاطمه أسعد ‪ ..‬نعيــم ‪ ..‬نور حمدان ‪ ..‬أمين محاجنه‬

‫‪ ..‬عبدالله "لحلوحي" ‪ ..‬ناصر العنزي ‪ ..‬علي كاظم‬

‫‪God bless you all‬‬


‫‪‬‬