Change over days can be inflammatory
Degree of change: change over days can be inflammatory. You can see tumors that grow that actually physically will increase in size extremely rapidly. Frequently it’s a matter of obstruction. Perhaps it’s a central necrosis that’s gotten secondarily infected. But for the most part things that oscillate in size or grow very rapidly are probably not tumors. Enlarging with straining, of course you are going to think of these other entities.
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The next thing, when you’ve outlined the history you may ask the patient, if it looks like an enlarged mass – it doesn’t feel like cancerous, it’s not rock hard. It’s a little bit spongy, it could be lymphoma. You’ve asked them about night sweats, fevers, chills, weight loss, those kinds of things and you’ve asked them, “Have you been exposed to TB? Do you have a cat? Do you clean the litter box?” you know, for toxoplasmosis. We see these things occasionally, but after you’ve kind of gone through those things then it’s time to start looking a little bit more at the mass itself. Number one, where is it located? Anterior border of the sternocleidomastoid could basically be anything. You know, that’s where your branchial clefts occur, that’s where your nodes are, so you could have inflammatory nodes and then that’s also the primary area where we are going to find metastatic disease from the upper digestive tract.
Midline masses are almost always benign. You can get some thyroid cancers that will present to a delphian node, but for the most part these are all benign thyroglossal duct cysts, dermoids, etc. And the age of your patient, smoking history, etc. If it’s a child you are going to be thinking more of the congenital things. Dermoid cysts, etc. Close to the border of the sternocleidomastoid you can get metastatic disease from the nasal pharynx and that’s the classic spot for that, but usually those are inflammatory nodes. Especially in a kid they are invariably inflammatory and even in adults, those are much less likely to be a cancer. You can see lymphomas there but again that’s much less likely. Basically what we are trying to do is get the original Gestalt as to how we are going to follow this patient up. Should I get a CAT scan first? Should I get a fine needle? Should I get a barium swallow? What’s the first thing? Order cialis super active online at canadian pharmacy. Does somebody need to put them to sleep and look? Where do we need to go? Supraclavicular masses – although cystic hygromas in kids – but usually, in about 90% of supraclavicular that are malignant you are looking at a malignancy below the clavicles. The classic is stomach and GI tract, but the most common in a woman is either breast or lung and most common in a man is lung by far. Almost all of them.
We talked about size. Size over 2 cm rarely inflammatory except in some of these stranger diseases that we don’t see very often. Consistency is important to some degree. Cancer nodes, especially squamous cell – which is 95% of head and neck cancers – are usually rock hard. They are fixed to things. They are non-tender of course and patients – virtually every patient that I have will tell me – “Well, I had this mass but I didn’t get too concerned about it because it didn’t hurt.” Well, those are the ones that you get concerned about, the ones that don’t hurt, because those are the ones that are tumors. If they are attached to the skin you need to think about the things that occur in the skin. The inclusion cysts etc. but also tumors can fixate to the skin. Again, that’s a late effect and usually the patient is in trouble. If they are deep to the skin but non-tender, soft, very very soft spongy, discreet, certainly lipomas, fibromas, neurofibromas, those things can all occur there as well.
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Congenital lesions: frequently cystic. They are all non-tender. They can sometimes transilluminate. I haven’t found that to be too useful. If they are pulsatile or if you have a bruit, and again we have to remember to do this occasionally – especially when you get a high jugular node – I will always tell them that when you are feeling it, to have the residents or whoever is examining a patient. To just pause for a second when you are feeling that node. Every once in awhile you’ll find somebody with a carotid – a thin person that has a high node that you are sent in for – the first thing you want to do is, you’ve done your exam and you are ready to do your fine needle, just put your finger on it and pause for a second. Every once in awhile you’ll find it pulsating. It can be a carotid body tumor, can be the carotid bulb itself and you get a surprise when you put a needle in those and that’s something you don’t want to happen. We have that happen a couple of times a year. Glomus tumors will also do that too. Red, tender, warm, of course you are thinking inflammatory.