Dentinal Tubules
Cervical LymphadenopathyBy Garry WilsonBackgroundThe majority of conditions that arise in the neck manifest as swelling. The importance of effective history taking and physical examination requires no further stressing from this author, but there are of course certain questions that can be asked of the patient that will help the clinician come to a differential, and eventually, a definitive diagnosis of the condition. The most common cause of swellings in the neck area is an enlarged lymph node, and if it is deduced that in any given case that it is indeed an enlarged lymph node that is giving rise to the swelling, the clinician must be sure to gather as much information as possible as to the nature of the symptoms experienced by the patient, as the two most common causes of enlargement of lymph nodes in the neck is infection and tumour metastases, so it is indeed prudent and necessary to know of the differing symptoms in each case, in order to best understand the condition. Systemic illnessInfective causes of the swelling will, in the majority of cases, be indicated by symptoms such as: FeverStiffness of the neck General feelings of lethargy and malaiseNeoplastic causes of the swelling often bring such symptoms as:Loss of appetiteDysphagia (dependent on specific site)Persistent dry coughHoarseness of the voiceImportant Questions To AskThere are a lot of questions that we can ask as healthcare providers in order to glean more information from patients, especially when changes they may find trivial or benign, that for this reason they neglect to mention, which may help us in making the correct diagnosis. Common questions that can help us arrive at the correct diagnosis would include questions about:Changes in appearance of the soft tissues of the mouth and/ or associated painSore throat or pain on swallowingDysphagia and if anything exacerbates/ alleviates any difficulty in swallowingChanges in the voice, i.e. hoarseness, change in pitch, change in volume, greater effort required in order to talkNasal problems such as a blocked or runny noseCancers of the head and neck very often metastasise in the lymph nodes of the neck, so it is important to be aware of the very differing manifestations of neoplastic and infectious pathologies. Physical Examination- SiteIn order to describe the location of a swelling in the neck, it is easiest to use the anterior and posterior triangles of the neck. Anterior triangleThe anterior triangle is defined as the lower border of the mandible, the anterior border of sternocleidomastoid (SCM) and the midline of the neck.Posterior triangleThe posterior triangle is bounded by the posterior border of sternocleidomastoid, the anterior order of trapezius and the clavicle. In order to properly visualise the triangles in the vast majority of patients, i.e. those who do not have a very low body fat percentage, it is necessary to have the patient tense sternocleidomastoid and trapezius simultaneously. This is done by placing your hand underneath the patient’s chin and asking them to move their head downwards against the resistance you are offering. To activate trapezius, the patient should be asked to shrug their shoulders against the resistance of your hand placed on the shoulder. The Location Of Lumps Relative To Anatomical LandmarksTracheaSwellings that are fixed to the trachea will of course move as the trachea moves. The easiest way to assess movement of the trachea is during swallowing, and this can of course be facilitated by asking the patient to take a few gulps out of a glass of water.MusclesIf you suspect that a lump is associated with a muscle, you should palpate the lump with the muscles in both a relaxed state and when tensed. Causes Of Cervical Lymph Node EnlargementEnlarged lymph nodes are the primary cause of swellings in the neck, and although it may appear that only one node is swollen or tender, it is likely that adjacent nodes are also suffering from some degree of pathology. The 4 main causes of cervical lymph node enlargement are:-Infection-Metastases-Primary Reticuloses-Sarcoidosis Infection Infection can be split into bacterial and viral aetiologies, and include such ailments as tonsillitis and glandular fever.MetastasesTumours from anywhere in the head and neck, as well as tumours from sites in the chest and abdomen can all metastasise via the cervical lymph tissue. Primary ReticulosesNeoplasms can occur in lymph tissues, and can be either benign (lymphoma) or malignant (lymphosarcoma).SarcoidosisSarcoidosis is the collection of granulomas in a tissue, the neck being a very common site in sufferers of the disease. The exact cause of sarcoidosis is yet to be fully established, but amongst the hypotheses are thyroid disease, with sarcoidosis being one of the sequelae, and autoimmune disease, especially coeliac disease. I will now discuss neck lumps of very differing aetiologies, which will give a more clinical idea of how different lumps present and the key differences in the presentations that will allow us as practitioners to distinguish between them and diagnose accordingly.Non- Specific Inflammatory LymphadenopathyThis commonly presents in children, and follows recurrent bouts of tonsillitis. The most common symptom is a painful lump in the digastric triangle, and patients often present complaining of a sore throat, which is exacerbated by swallowing. Due to the young age of the patient, it is often noticed by the parent of the child, especially if the child starts snoring, which is common, and an acute difficulty in breathing brought about by the presence of the inflammation. The pain on swallowing means the patient is normally reluctant to eat, and exhibits a general feeling of malaise, and the parents often note that the patient is crying more than usual and is generally more lethargic. This is a classic presentation of infected lymph nodes, and is not confined to children, but this is just an example. The enflamed nodes in cases of infection are normally tender and have several systemic effects, with a feeling of malaise and weight loss/ reticence to eat amongst the most common. Cancerous Lymph NodesCervical metastases are extremely common in cancers of the head and neck, and it is of paramount importance for any healthcare provider to perform a thorough examination of the patient to try and ascertain the primary neoplasm if the patient is unaware that they may indeed have a cancerous growth. Again, asking probing questions about any changes the patient has noticed in their body at all may give some clues as to the site of the neoplasm, and indeed possibly an idea as to how long it has been present. One of the, for want of a better term, problems, with cancerous growths are that they are often painless; this is often reflected in how long some patients take to seek the help of a doctor or dentist with the problem, a common misgiving being that if it is painless, it must be fairly innocuous. Sadly, this is not always the case. Although the lump itself may be painless, it may be that the associated symptoms are what has compelled the patient to seek help, such as a possible sudden difficulty in swallowing, a hoarse voice, although these are just examples, and other symptoms do occur, such as a sore throat. Due to the high concentration of epithelia in the head and neck region, it is most often carcinomas that metastasise via the lymphatic system. Cancerous nodes tend not to be warm or cause discolouration of the skin, unlike infected nodes (in accordance with the cardinal signs of inflammation- calor, rubor, tumor, dolor and functio laesa). Another key means of distinguishing cancerous nodes from infected ones is in their hardness. Cancerous nodes are normally very hard; whereas infected ones, although they can also be hard, tend to fluctuate under palpation. Carotid Body TumourThis is the third and final type of lump in the neck that will be reviewed in this article, as it offers us the chance to look at a structure other than the lymph nodes, and serves as a reminder that not only the cervical lymph nodes are the source of lumps in the neck, but also, in this case, one of the 2 arteries that supply the brain, and a large portion of the head and neck area as a whole. It is a tumour of the chemoreceptor tissue in the carotid body, which is important in the monitoring and regulation of blood oxygen and carbon dioxide levels, and hence heart rate. Patients are very rarely under the age of 40, and will complain of a slowly- growing lump in the anterior triangle, adjacent to the anterior border of sternocleidomastoid. The lump is likely to pulsate, which, considering its location, is hardly surprising. When palpating the lump, great care must be taken not to apply too much pressure in the region of the carotid artery, as a vasovagal episode may ensue. In fitting with the symptoms earlier described in cases of neoplastic changes on the neck, the lump should not be hot, nor should the overlying skin be discoloured. It is very rare that carotid body tumours become malignant, but as in any case of suspected neoplasm, this should not be ruled out. ConclusionThis has been a brief run- through of some of the various pathologies that can manifest as a lump in the neck, and I hope that I have been able to help distinguish between the differences in the underlying causes, and therefore help improve understanding of these conditions and how we as healthcare professionals can then alter our response and subsequent actions in order to do the best we can by the patient, as we should always be striving to do. ................
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