0:01

The fourth clinical scenario that we often see in the

0:04

emergency department as a neuroradiologist,

0:07

is a neck or face mass.

0:10

And this is new evaluation of a neck or face mass.

0:14

Now, these are generally separated into those that are

0:17

associated with fever and those that are afebrile.

0:20

So, this is not pharyngitis. This is not airway narrowing,

0:23

This is not drooling and difficulty swallowing.

0:26

This is a patient who presents with a neck mass. In the adult,

0:30

the two most common neck masses that we see are thyroid

0:36

lesions and lymphadenopathy. In children,

0:41

far and away,

0:42

the most common lesions that we see in the neck are lymph nodes,

0:46

and they are usually just inflammatory

0:48

lymph nodes in children.

0:50

So let's look at a typical case under this scenario.

0:55

So here we have a patient and we mark that the patient is febrile

1:00

and we notice that we have the carotid artery and

1:03

the jugular vein. Carotid artery and jugular vein.

1:05

We're at the level of the aryepiglottic folds.

1:08

So we're at the superglotic level,

1:10

probably around the C3-C4 level.

1:13

And you see the lymph nodes here that are present

1:17

and showing peripheral enhancement.

1:19

So these are inflammatory lymph nodes

1:22

in the left side of the neck.

1:24

Based on the fact that we are below the level of the hyoid

1:28

bone, but above the level of the cricoid cartilage,

1:31

we would call these Level III lymph nodes.

1:33

Remember that for Level V lymph nodes,

1:37

the lymphadenopathy has to be completely behind the

1:40

posterior margin of the sternocleidomastoid muscle.

1:43

This lymph node is just a little bit superimposed on the

1:47

posterior margin and the sternocleidomastoid, and

1:50

therefore would still be called Level III lymph node.

1:52

This necrotic lymph node would be called a Level V

1:55

lymph node. Here you can see, for example,

1:58

a Level V lymph node, small in size, within normal limits.

2:02

Here are these tiny little Level III lymph nodes because they

2:05

are not completely behind the posterior margin

2:08

of the sternocleidomastoid muscle.

2:10

That's how we name the lymph nodes.

2:13

So, in an adult with these type of lymph nodes,

2:18

our considerations are, is this secondary to an infection, or is

2:22

this secondary to a primary head and neck aerodigestive

2:26

system carcinoma? With the history of fever,

2:30

we're going to be much more concerned about

2:32

an infectious etiology. And worldwide,

2:36

we'd probably consider tuberculosis as one of the more

2:40

common of the causes of necrotic lymphadenitis in an adult.

2:47

In America,

2:48

we don't see tuberculosis nearly as

2:50

much as other areas of the world,

2:52

and therefore the most common etiology in our situation would

2:56

probably still be staph. or strep. infection and/or those

3:00

individuals who may have IV drug abuse and/or AIDS that can have

3:06

any number of necrotic lymph nodes on an infectious basis.

Clinical Scenario 4: Mass in the Neck Introduction

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