1. 頸部腫脹 Mass in the Neck 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

2. 學 習 目 標
明白頸部腫脹之鑑別診斷

3. 參考資料
References:
Wood, Goaz. Differential Diagnosis of Oral Lesions. Mosby Publisher, 3rd Edition, Chapter 29,
自購網路資源：super_toolcool
網路資源 (anonymous)
口腔影像的臨床診斷, 2nd edition, Chapter 12, p.283
Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 31, p
Kaohsiung Medical University Oral Pathology
Crispian Scully. Handbook of oral disease - diagnosis and management. Martin Dunitz Publisher, 1st ed. p , 376
Yeshwant B. Rawal, Carl M. Allen, John R. Kalmar.
A nodular submental mass. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:734-7
彼得 史彼爾人. 漢聲雜誌 民國86, 5月, p. 8
Carlson ER et al. Neck dissections for oral/head and neck cancer: J Oral Maxillofac Surg 2006;64:4-11
Misra S et al. Management of gingivobuccal complex cancer. Ann R Coll Surg Engl 2008;90:546-53
WoolgarJ et al. Neck dissections: A practical guide for the reporting histopathologist. Current Diag Pathol 2007;13:

4. Mass of the Neck Constitutes a small % of the total body area
Contains many vital
anatomic structures
& diverse tissue types
Diverse and varied
pathological lesions
Examination of neck
should be performed
in patient evaluation
Refs. 2, 3, 9

5. Mass of the Neck A rule of thumb for the duration of the mass
Day (7 days): Inflammatory lesions
Month (7 months): Neoplasm
Year (7 years): Congenital lesions

6. Mass of the Neck Mass of nonspecific location
Certain lesions are found in discrete
anatomic locations
A knowledge of those lesions
associated with specific regions in the
neck is useful
Regional approach
Mass of nonspecific location
Skin & subcutaneous tissues
within the neck
- mobile skin
- cervical fascia
Ref. 2

7. Mass of the Neck Mass of specific location
‘Which’ region will have ‘which’ lesions
Mass of specific location
Masses in submandibular region
Masses in parotid region
Masses in median-paramedian region
Masses in lateral region
Ref. 1
submandible
parotid
(para)median
lateral

8. Mass of the Neck 1. Submental node 2. Submandibular node
3. Cranial jugular
(deep cervical) node
4. Medial jugular
5. Caudal jugular
6. Dorsal jugular (superficial
cervical) node along accessory n
7. Supraclavicular node
8. Prelaryngeal & paratracheal node
9. Retropharyngeal node
10. Parotid node
11. Buccal node
12. Retroauricular & occipital node
12 cervical lymph nodes
Ref. 1

9. Mass of the Neck Levels I-V: Basis of
the nomenclature for the classification of neck dissections for oral/head & neck cancers
Levels 1-III:
Sentinel LN of
oral cancer
(1st meta LNs)
Refs. 10, 11

10. Mass of the Neck
Ref. 10

11. Mass of the Neck
Ref. 12

12. Mass of the Neck
Ref. 12

13. Mass of the Neck
Ref. 12

14. Mass of the Neck
Ref. 12

15. Mass of the Neck
Ref. 12

16. Mass of the Neck
Ref. 12

17. Mass of the Neck 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

18. Mass of the Neck 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

19. Mass of the Neck Find the origin: - Infection: lymphoid hyperplasia
: acute lymphadenitis
Infection source- pericoronitis
(third molar)
- infected cyst
- metastatic cervical node
Primary tumor – oral SCC, NPC, others
- lymphoma (solitary/multiple; uni/bilateral)
History, biopsy, imaging examination
Ref. 2

20. Mass of the Neck 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

21. Mass of the Neck 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

22. Mass of the Neck Locate the origin: - Infection: lymphoid hyperplasia
: acute lymphadenitis
Infection source- infected cyst
(congenital preauricular cyst,
sebaceous cyst)
- metastatic parotid node
Primary tumor – oral SCC, NPC, others
- lymphoma (solitary/multiple; uni/bilateral)
Biopsy, imaging examination
Ref. 2

23. Mass of the Neck 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 hand
Refs. 2, 4, 5

24. Mass of the Neck 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

25. Mass of the Neck Xerostomia Biparotid enlargement Dry eye
Primary Sjogren syndrome
Secondary Sjogren syndrome
Conjunctivitis
sicca
Connective tissue
disease (auto-
immune disease)
Ref. 7

26. Mass of the Neck 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

27. Mass of the Neck Chief Complaint
A swelling mass of R’t parotid area
Ref. 6

28. Mass of the Neck Present Illness
This 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.

29. Mass of the Neck Personal History
Alcohol (-)
Betel quid (-)
Smoking (-)
Denied other special habits

30. Mass of the Neck Past History
Past Medical History
 Denied any systemic disease
 Drug allergy (+) : unknown
Past Dental History
 OD
 Prosthesis
 Tooth Extraction
 Full mouth scaling

31. Mass of the Neck Clinical Examination
Extra-oral
Fluctuation: __
Pain: __
Tenderness: +
Mobility: movable
Induration: __
Lymphadenopathy: __
Ref. 6

32. Mass of the Neck CT Findings
Petrous effect
Ref. 6

33. Features Suggestive of Benignancy
Movable (except palate)
Unattached to skin or mucosa (except palate)
No ulceration of skin or mucosa
Slow growth
Long duration
No pain
No facial nerve palsy
Features Suggestive of Malignancy
Induration
Fixed to overlying skin or mucosa
Ulceration of skin or mucosa
Rapid growth; Growth spurt
Short duration
Pain, often severe
Facial nerve palsy
Ref. 6

34. Infection or Benign / Malignant
Mass of the Neck
Infection or Benign / Malignant
Pain (-)
Growing slowly (5~6 years)
Smooth surface
CT findings : demarcated margin
No other structure destruction
 Benign Tumor

35. Mass of the Neck Working Diagnoses
Pleomorphic Adenoma
Warthin’s Tumor
Basal Cell Adenoma
Oncocytoma

36. Mass of the Neck 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

37. Mass of the Neck 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, y/o
Associated with smoking

38. Mass of the Neck 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

39. Mass of the Neck 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

40. Clinical Impression Mass of the Neck Pleomorphic Adenoma, right
parotid gland

41. Mass of the Neck Excisional Biopsy
Ref. 6

42. Mass of the Neck Excisional Biopsy
Ref. 6

43. Mass of the Neck Excisional Biopsy
Ref. 6

44. Mass of the Neck Excisional Biopsy
Ref. 6

45. Histopathological Diagnosis
Mass of the Neck
Histopathological Diagnosis
Pleomorphic adenoma
Rt parotid gland
Ref. 2

46. Mass of the Neck 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
(重要)
Ref. 1

47. Mass of the Neck 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

48. Mass of the Neck 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

49. Mass of the Neck 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

50. Mass of the Neck D.D. of masses in median-paramedian region
1. Thyroglossal duct cyst
2. Epidermoid/dermoid cyst
3. Submental lymphadenitis
4. Submental abscess
5. Thyroid gland tumor
6. Ectopic thyroid gland
Ref. 3

51. Mass of the Neck
6. Ectopic thyroid gland
(Fig. below).
Ref. 7

52. Lateral region (low-level)
Mass of the Neck
Lateral region (low-level)
1. Intrathoracic goiter
2. Esophageal fibroma
3. Metastatic carcinoma
4. Sarcoidosis
Ref. 3

53. Lateral region (high-level)
Mass of the Neck
Lateral region (high-level)
1. Salivary gland tumor
2. Sialadenitis
3. Carotid body tumor
4. Branchial cleft cyst (2nd arch)
5. Cystic hygroma
6. Neurofibroma
7. Fibroma
8. Hemangioma
9. Plunging ranula
10. Enlarged nodes
Ref. 3

54. Mass of the Neck 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

55. Mass of the Neck
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.
Ref. 8
What is your differential diagnosis after studying this lecture?

56. Summaries
明白頸部腫脹之鑑別診斷原理，並知道其中的應用。