口腔診斷學陳玉昆副教授 : 高雄醫學大學口腔病理科 07-3121101~2755...

口腔診斷學

陳玉昆副教授 : 高雄醫學大學口腔病理科 07-3121101~2755 [email protected]

Mass in the Neck頸部腫脹

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


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


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 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


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


Ref. 12



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 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


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 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 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


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 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 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


Biparotid enlargement

Xerostomia

Dry eye

Primary Sjogren syndrome

Secondary Sjogren syndrome

Xerostomia Conjunctivitissicca

Connective tissuedisease (auto-immune disease)

Ref. 7


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


Chief Complaint A swelling mass of R’t parotid area

Ref. 6


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.


Personal History

Alcohol (-) Betel quid (-) Smoking (-) Denied other special habits


Past History Past Medical History Denied any systemic disease Drug allergy (+) : unknown Past Dental History OD Prosthesis Tooth Extraction Full mouth scaling


Clinical Examination

Fluctuation: __

Pain: __

Tenderness: + Mobility: movable Induration: __

Lymphadenopathy: __

Extra-oral

Ref. 6


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


Benign Tumor

Working Diagnoses

Pleomorphic Adenoma Warthin’s Tumor Basal Cell Adenoma Oncocytoma



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



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


Pleomorphic Adenoma, right

parotid gland

Clinical Impression



Excisional Biopsy

Ref. 6

Pleomorphic adenoma

Rt parotid gland

Mass of the NeckMass of the NeckHistopathological

Diagnosis

Ref. 2


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 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 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 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


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


6. Ectopic thyroid gland

(Fig. below).

Ref. 7


1. Intrathoracic goiter

2. Esophageal fibroma

4. Sarcoidosis

3. Metastatic carcinoma

Lateral region (low-level)Lateral region (low-level)

Ref. 3


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


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


SummariesSummaries明白頸部腫脹之鑑別診

斷原理，並知道其中的應用。

口腔診斷學 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755...

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口腔診斷學陳玉昆副教授 : 高雄醫學大學口腔病理科 07-3121101~2755...