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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

0:58

with the submandibular gland.

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The patient will usually complain about pain around the

1:03

angle of the jaw or in the submandibular gland itself.

1:06

And that is secondary to the obstruction of the

1:10

flow of saliva secondary to a large stone.

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It's important to comment whether or not this

1:16

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,

1:25

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

1:28

radiates into the floor of the mouth along the expected

1:31

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

1:39

proximal portion of wharton's duct

1:42

in the floor of the mouth.

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Remember that the floor of the mouth is identified as the

1:46

sublingual space and the mylohyoid muscle musculature,

1:52

which is just lateral to the sublingual space.

1:56

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

2:20

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

2:50

muscle and the submandibular gland.

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The branchial cleft cysts are separated into

2:56

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

3:07

muscle but lateral to the carotid sheath.

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Bailey's type three, which invaginate into the carotid

3:14

sheath. And Bailey's type four,

3:16

which are medial to the carotid

3:19

sheath in the parapharyngeal space.

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

3:24

muscle but lateral to the carotid sheath, would represent

3:29

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

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Branchial cleft cyst can get super infected and lead

3:38

to an inflammatory process in the neck.

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But more likely than not,

3:43

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

3:48

because one can have cystic lymphadenopathy associated

3:54

with a squamous cell carcinoma in a patient who is

3:56

afebrile. Cystic lymphadenopathy would not be nearly

4:00

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

4:05

But cystic lymphadenopathy is characteristic

4:09

of HPV positive oropharyngeal cancers.

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So those cancers that are associated with the HPV virus,

4:20

and often in younger patients than the smokers and drinkers

4:24

that we normally normally see, squamous cell carcinoma,

4:27

HPV-positive cancers are associated with cystic

4:31

lymphadenopathy. Here's a different patient,

4:34

actually three different patients,

4:36

all of whom have lymphedenopathy

4:39

that's not associated with fever,

4:41

that's not associated with an infection.

4:44

In this case, it was tuberculosis,

4:47

even though the patient was afebrile with these necrotic

4:51

cystic lymph nodes. Differential diagnosis,

4:54

again with cystic lymph nodes, includes thyroid cancer,

4:58

which is another source of

5:00

cystic lymphadenopathy. This was a patient who,

5:02

although was afebrile, had mononucleosis. Usually large,

5:08

low density lymph nodes,

5:10

sometimes associated with fever,

5:12

sometimes associated with a sore throat,

5:14

sometimes associated with a pharyngitis,

5:16

but you can have it with just massive lymphadenopathy.

5:19

This was the patient who had large lymph

5:21

nodes in the supraclavicular fossa.

5:24

And you see the two two lymph nodes here,

5:26

posterior to the jugular vein on the left side.

5:30

When you have supraclavicular lymphadenopathy without fever,

5:34

we worry about Hodgkin's lymphoma.

5:37

Now, Hodgkin's lymphoma may have B symptoms,

5:39

which include fever and weight loss and night sweats,

5:42

but the patient may not have the quote-unquote

5:46

B symptoms and just present with supraclavicular

5:49

lymphadenopathy.

5:50

If you have contrast enhancing of lymphadenopathy

5:53

in the supraclavicular fossa,

5:55

you may want to think about angiofollicular hyperplasia, or

6:00

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

6:03

These are all causes of enlarged lymph

6:06

nodes in different areas of the neck.