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Case 20 - Afebrile

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So far we've looked at masses in the neck

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that are associated with a fever,

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and we looked at the most common being, lymphadenopathy.

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And then we segued from lymphadenopathy into

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the retropharyngeal space to distinguish between

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retropharyngeal edema, phlegmon, and abscess,

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as well as the retropharyngeal lymphadenopathy.

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Now, let's talk about masses or abnormalities in

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the neck that are not associated with fever.

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Quite often, the patient will present with

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either a painful mass in the neck, or

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just a lump that they newly feel. In an adult,

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again, the most common of these is going to

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be a thyroid nodule or a lymph node.

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Here's an example of another entity

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that can lead to a mass in the neck,

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and that is a calcification that is associated

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with the submandibular gland.

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The patient will usually complain about pain around the

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angle of the jaw or in the submandibular gland itself.

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And that is secondary to the obstruction of the

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flow of saliva secondary to a large stone.

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It's important to comment whether or not this

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calcification is actually in the submandibular gland.

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Here's the normal left gland, or whether it's in the duct.

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More commonly,

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those that are in the duct are going to cause pain which

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radiates into the floor of the mouth along the expected

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course of wharton's duct, the duct of the submandibular gland.

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So here we see a large calcification that's in the

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proximal portion of wharton's duct

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in the floor of the mouth.

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Remember that the floor of the mouth is identified as the

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sublingual space and the mylohyoid muscle musculature,

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which is just lateral to the sublingual space.

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This is what we would call sialolithiasis,

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or stone in the gland, or sialodocholithiasis,

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stone in the duct of the gland.

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Doco referring to the duct of the gland.

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Here's a different patient with a markedly enlarged mass

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that is in the left side of the neck and displacing

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the submandibular gland anteriorly.

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Now, this large mass is in a patient who is afebrile.

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So this is not likely to be an inflammatory lymph node.

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In this case,

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we have a somewhat thickened wall to this cystic cavity,

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and this represents a branchial cleft cyst.

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The most common of the branchial cleft

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cyst is the second branchial cleft cyst.

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Typically occurring between the sternocleidomastoid

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muscle and the submandibular gland.

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The branchial cleft cysts are separated into

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those that are Bailey's type one, which

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are superficial to the sternocleidomastoid muscle.

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Bailey's type two,

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which are deep to the sternocleidomastoid

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muscle but lateral to the carotid sheath.

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Bailey's type three, which invaginate into the carotid

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sheath. And Bailey's type four,

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which are medial to the carotid

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sheath in the parapharyngeal space.

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This, for example, because it's deep to the sternocleidomastoid

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muscle but lateral to the carotid sheath, would represent

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a Bailey's type two, second branchial cleft cysts.

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Branchial cleft cyst can get super infected and lead

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to an inflammatory process in the neck.

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But more likely than not,

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you see them just as a cystic lesion in the neck. Beware

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because one can have cystic lymphadenopathy associated

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with a squamous cell carcinoma in a patient who is

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afebrile. Cystic lymphadenopathy would not be nearly

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as large as this. They usually are less than 3 cm in size.

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But cystic lymphadenopathy is characteristic

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of HPV positive oropharyngeal cancers.

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So those cancers that are associated with the HPV virus,

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and often in younger patients than the smokers and drinkers

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that we normally normally see, squamous cell carcinoma,

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HPV-positive cancers are associated with cystic

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lymphadenopathy. Here's a different patient,

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actually three different patients,

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all of whom have lymphedenopathy

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that's not associated with fever,

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that's not associated with an infection.

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In this case, it was tuberculosis,

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even though the patient was afebrile with these necrotic

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cystic lymph nodes. Differential diagnosis,

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again with cystic lymph nodes, includes thyroid cancer,

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which is another source of

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cystic lymphadenopathy. This was a patient who,

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although was afebrile, had mononucleosis. Usually large,

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low density lymph nodes,

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sometimes associated with fever,

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sometimes associated with a sore throat,

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sometimes associated with a pharyngitis,

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but you can have it with just massive lymphadenopathy.

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This was the patient who had large lymph

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nodes in the supraclavicular fossa.

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And you see the two two lymph nodes here,

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posterior to the jugular vein on the left side.

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When you have supraclavicular lymphadenopathy without fever,

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we worry about Hodgkin's lymphoma.

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Now, Hodgkin's lymphoma may have B symptoms,

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which include fever and weight loss and night sweats,

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but the patient may not have the quote-unquote

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B symptoms and just present with supraclavicular

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lymphadenopathy.

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If you have contrast enhancing of lymphadenopathy

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in the supraclavicular fossa,

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you may want to think about angiofollicular hyperplasia, or

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the name, the eponym for that is castleman's disease.

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These are all causes of enlarged lymph

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nodes in different areas of the neck.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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