Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Lumps in the Head and Neck and Salivary Calculi


Introduction

Neck lumps are common and may be related to disorders of the mouth, throat or skin. Infection in the cervical region can cause difficulty swallowing (dysphagia) and put the airway at risk. Referrals are often made to exclude malignancy, whilst some are for surgical treatment of a metabolic disorder, such as thyrotoxicosis or hyperparathyroidism. There is a large overlap with specialties in this area, notably ear, nose and throat (ENT), oral and maxillofacial surgery, plastic surgery and dermatology.

Thyroid swellings may be confused with other anterior neck swellings, so head and neck examination must include the thyroid area, described in Chapter 49 .

In hospitals, mouth problems are managed by oral and maxillofacial surgeons, but patients often obtain advice first from other clinicians, particularly in emergency departments. As such, it is important they understand the presentation of oral and dental disease and appreciate the necessary management (see also Ch. 48 ).

History and Examination in the Head and Neck

Many different tissues are concentrated here, so there is a profusion of conditions causing lumps. Box 47.1 provides a simple classification.

BOX 47.1
Causes of a Lump in the Head or Neck
AIDS, Acquired immunodeficiency syndrome.

  • 1.

    Thyroid disorders (classified in Table 49.1 )

  • 2.

    Lymph node enlargement

    • —

      Local inflammatory lymphadenopathy from acute infections of the head and neck

    • —

      Inflammatory lymphadenopathy, as part of a generalised lymphadenopathy, for example, glandular fever or AIDS-related lymphadenopathy

    • —

      Local inflammatory lymphadenopathy from chronic infections, for example, tuberculosis

    • —

      Lymphomas

    • —

      Secondary tumour deposits (metastases)

  • 3.

    Congenital cysts —thyroglossal, branchial and preauricular cysts, external angular dermoids and cystic hygroma (lymphatic malformations)

  • 4.

    Salivary gland disorders —adenoma, carcinoma, stones, rare autoimmune disorders, such as Sjögren syndrome

  • 5.

    Lumps in the skin —any skin lesion may occur in the head and neck, but the main problem is one of differential diagnosis, for example, lipomas and epidermal cysts

  • 6.

    Rare tumours —carotid body tumours, carcinoma of the maxillary sinus (antrum), tumours and cysts of the jaw

  • 7.

    Actinomycosis (very rare)

Special Points in the History and Examination

As always, the history provides important clues to the diagnosis. The patient’s age, the rate of growth of the lump and symptoms, such as pain, discharge or swelling related to eating (‘mealtime syndrome’) may point to the diagnosis.

Most lumps are best examined with the patient sitting, so the examiner can palpate from in front and behind. The examiner should establish the characteristics of the lump ( Box 47.2 ) and determine how it relates to overlying or underlying structures. For example, a lump in the cheek may originate in skin, parotid, buccinator muscle, oral mucosa or parotid duct. In clinical examinations, it is useful to describe the characteristics as if to someone who cannot see the patient.

BOX 47.2
Characteristics of any Lump on Clinical Examination

  • Site

  • Size

  • Shape

  • Surface characteristics

  • Fixation (superficial and deep)

  • Anatomical origin

  • Consistency

  • Fluctuance

  • Pulsatility

  • Temperature

  • Transilluminability

  • Bruit (blood flow murmur)

  • Local lymphadenopathy

With a lump or swelling, the whole of scalp, back of neck and skin behind and in the ears should be examined. Head and neck lymph nodes must be palpated. A simple method considers nodes lying in two planes, horizontal and vertical ( Fig. 47.1 ), which can be examined systematically. For lumps in the lower half of the face or submandibular region, the oral cavity should be examined to exclude salivary gland lesions, oral malignancies or sources of infection, such as a dental abscess. For lumps in the parotid region, the integrity of the facial nerve should be tested since malignant tumours often cause neurological deficits. If the presenting complaint is lymph node enlargement , nasendoscopy of upper airways and pharynx may be necessary to exclude primary tumours or infected lesions.

Fig. 47.1, Simple Technique for Palpating Head and Neck Lymph Nodes.

Examination of the Oral Cavity

For many doctors, asking the patient to open the mouth represents the entire oral examination; however, the simple but thorough technique illustrated in Fig. 47.2A–D , will enable most significant lesions to be seen without special instruments.

Fig. 47.2, Technique of Oral Examination.

First, the patient should remove dentures. Then lips and their mucosal lining, and the lining of cheeks and gums are inspected. To do this, the lips are retracted by the examiner’s gloved fingers or a wooden spatula and the mouth illuminated with a pen torch. Teeth are inspected for obvious decay and gum inflammation. A flap of gum over a partially erupted lower wisdom tooth can cause painful inflammation (see Fig. 48.6 ).

If parotid disease is suspected, the duct papilla opposite the upper second molar should be identified and palpated. If the patient has dentures or irregular teeth, inspect for papillary scarring causing obstruction. The palate is best examined if the patient tilts the head backwards. Finally, the tongue and floor of the mouth are inspected for mucosal lesions. To assist, the patient first protrudes, then elevates the tongue before finally pushing the tongue towards the left and right cheeks.

Lumps in the floor of the mouth, submandibular area and cheeks should be palpated bimanually as shown in Fig. 47.2D . Lumps in these areas are often mobile and tend to move away from examining fingers.

Tumours of Salivary Glands

There are three pairs of major salivary glands, parotid , submandibular and sublingual . The parotid produces serous (watery) saliva, the submandibular a mixed seromucous saliva and the sublingual a more mucous secretion. The parotid and submandibular glands each drain into the mouth via long ducts, whereas the sublingual drains via multiple small ducts into the floor of the mouth, sometimes via the submandibular duct.

Surgical disorders of major salivary glands include benign and malignant tumours, stones, bacterial and viral infections and rare autoimmune disorders, all of which present as salivary gland lumps. The oral mucosa also contains numerous small ‘minor’ salivary glands, which can undergo neoplastic change or form retention cysts.

Salivary Gland Tumours

Pleomorphic Adenoma

Pleomorphic adenoma presents as slow growing, painless lumps ( Fig. 47.3 ). Most are in the parotid, some in the submandibular gland and a few are in minor salivary glands. Pleomorphic adenoma is the most common lump in the parotid and by far the most common salivary gland neoplasm. Eighty percent of parotid tumours are benign and of these, 80% are pleomorphic adenomas. They present in middle age or later, and both sexes are equally affected.

Fig. 47.3, Pleomorphic adenoma of major salivary glands.

Pleomorphic adenomas are derived from salivary gland epithelium and are benign but show variable differentiation. The name comes from the varied histological appearance. Columns and islands of neoplastic epithelial cells are separated by myxomatous connective tissue stroma, often with areas resembling immature cartilage. Some without myxomatous tissue are described as monomorphic .

Pleomorphic adenomas have a well-defined but thin capsule over a nodular surface, which is important when attempting removal, as there is a risk of incomplete excision and consequent recurrence. They also have a 1% year-on-year risk of malignant change (carcinoma-ex-pleomorphic adenoma).

Most parotid tumours occur in the superficial part, external to the plane of the facial nerve. Occasionally, they occur in the deep part in intimate association with the facial nerve. In either case, the tumour can extend between the nerve branches, but being benign, it does not invade the nerve to cause facial palsy. Facial nerve damage is a risk during excision, especially of deeper lesions. Patients should be warned of this possibility before operation.

If an older patient has a slowly growing solid parotid lump without facial palsy, it is best to assume it is a pleomorphic adenoma or Warthin tumour (adenolymphoma). Definitive diagnosis can usually be made by ultrasonography and core biopsy or by fine-needle aspiration cytology and confirmed histologically after excision. If malignancy is suspected, computed tomography scanning may be needed.

Treatment

Treatment is by excision. For superficial lesions, the standard operation has long been a superficial or partial superficial parotidectomy to excise all glandular tissue superficial to the facial nerve. This is effectively a facial nerve dissection. Nowadays, many surgeons perform extracapsular dissection of the lump alone and in benign disease, this cures the problem and carries a lower risk of side-effects, particularly facial nerve damage and Frey syndrome of gustatory sweating (see later). Recurrence is uncommon with either procedure. For deeper lesions, an attempt should be made to excise the entire lesion, carefully identifying and preserving the facial nerve branches.

Complications of Parotid Surgery

The main complication is facial nerve injury. Damage to the temporal or zygomatic branches may impair closure of the eye, leading to corneal drying and damage. Mandibular branch damage causes weakness at the angle of the mouth leading to oral incontinence and a lopsided smile. Nerve damage may also complicate submandibular gland excision: the mandibular branch of the facial nerve is vulnerable if the incision is sited too high. The lingual and hypoglossal nerves lie close to the deep surface of the gland; injury causes unilateral tongue wasting and numbness, respectively.

Salivary fistula is an occasional complication following parotid surgery, causing saliva to leak onto the face at mealtimes. The fistula usually resolves spontaneously after several weeks.

Frey syndrome is a late complication of superficial parotidectomy in 25% or more cases, but is virtually unknown after extracapsular dissection. It probably results from divided parasympathetic secretomotor fibres regenerating in the skin, where they assume control of sweat gland activity. Facial sweating occurs in response to salivatory stimuli; known as gustatory sweating , this can be embarrassing. It can be managed by use of fragrance-free antiperspirants or injection of botulinum toxin.

Adenolymphoma (Warthin Tumour)

This unusual benign lesion constitutes less than 10% of salivary neoplasms, and occurs almost exclusively in the parotid. They usually arise after middle age and there is a male predominance and a strong association with cigarette smoking. They sometimes occur bilaterally (up to 10%), at the same time or at different times.

Histologically, the tumour is composed of large glandular acini. The epithelium is embedded in dense lymphoid tissue with lymphoid follicles. Histogenesis is not understood, but the glandular part may be hamartomatous salivary duct tissue within a normal parotid lymph node.

Adenolymphomas are benign. They present as a parotid lump, clinically indistinguishable from pleomorphic adenoma. The diagnosis can usually be made by core biopsy or sometimes fine-needle aspiration cytology, then they are either enucleated or left alone. Adenolymphomas do not recur, but a satellite lesion may enlarge and present as another tumour.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts