口腔診斷學(xué)專題知識講座

口腔診斷學(xué)陳玉昆副教授:高雄醫(yī)學(xué)大學(xué)口腔病理科

07-3121101~2755MassintheNeck頸部腫脹學(xué)習(xí)目標(biāo)

明白頸部腫脹之鑑別診斷Wood,Goaz.DifferentialDiagnosisofOralLesions.MosbyPublisher,3rdEdition,Chapter29,634-5.自購網(wǎng)路資源：super_toolcool網(wǎng)路資源(anonymous)口腔影像旳臨床診斷,

2ndedition,Chapter12,p.283EricWhaites:Essentialsofdentalradiography&radiology3rdedition,Chapter31,p.403-414KaohsiungMedicalUniversityOralPathologyCrispianScully.Handbookoforaldisease-diagnosisandmanagement.MartinDunitzPublisher,1sted.p.267-8,376YeshwantB.Rawal,CarlM.Allen,JohnR.Kalmar.Anodularsubmentalmass.OralSurgOralMedOralPatholOralRadiolEndod2023;104:734-7彼得史彼爾人.漢聲雜誌民國86,5月,p.8CarlsonERetal.Neckdissectionsfororal/headandneckcancer:1906-2023.JOralMaxillofacSurg2023;64:4-11MisraSetal.Managementofgingivobuccalcomplexcancer.AnnRCollSurgEngl2023;90:546-53WoolgarJetal.Neckdissections:Apracticalguideforthereportinghistopathologist.CurrentDiagPathol2023;13:499-511References:參考資料MassoftheNeckContainsmanyvitalanatomicstructures&diversetissuetypesDiverseandvariedpathologicallesionsExaminationofneckshouldbeperformedinpatientevaluationConstitutesasmall%ofthetotalbodyareaRefs.2,3,9MassoftheNeckAruleofthumbforthedurationofthemass

Day(7days):InflammatorylesionsMonth(7months):NeoplasmYear(7years):CongenitallesionsMassoftheNeckCertainlesionsarefoundindiscreteanatomiclocations

Aknowledgeofthoselesionsassociatedwithspecificregionsintheneckisuseful

Massofnonspecificlocation

Skin&subcutaneoustissueswithintheneck

-mobileskin-cervicalfasciaRegionalapproachRef.2MassoftheNeckMassofspecificlocation

Massesinsubmandibularregion

Massesinparotidregion

Massesinmedian-paramedianregion

Massesinlateralregionsubmandibleparotid(para)medianlateral‘Which’regionwillhave‘which’lesionsRef.1MassoftheNeck1.Submentalnode2.Submandibularnode3.Cranialjugular(deepcervical)node4.Medialjugular(deepcervical)node5.Caudaljugular(deepcervical)node6.Dorsaljugular(superficialcervical)nodealongaccessoryn7.Supraclavicularnode8.Prelaryngeal¶trachealnode9.Retropharyngealnode10.Parotidnode11.Buccalnode12.Retroauricular&occipitalnode12cervicallymphnodesRef.1MassoftheNeckLevels1-III:SentinelLNoforalcancer(1stmetaLNs)Refs.10,11LevelsI-V:Basisofthenomenclaturefortheclassificationofneckdissectionsfororal/head&neckcancersRef.10MassoftheNeckRef.12MassoftheNeckMassoftheNeckRef.12MassoftheNeckRef.12MassoftheNeckRef.12MassoftheNeckRef.12MassoftheNeckRef.12MassoftheNeckMassofspecificlocation

Massesinsubmandibularregion

Lymphnodes:firstechelonnode-thefirstnodethatencounterthetumorcellormicroorganism

Lymphnodes:enlargement-Infection:lymphoidhyperplasia:acutelymphadenitis-metastaticcervicalnode-lymphomaRef.1MassoftheNeckMassofspecificlocation(觸診)

Massesinsubmandibularregion

Lymphnodes:enlargement-Infection:lymphoidhyperplasia

movable,painless,non-tender

:acutelymphadenitis

movable/fixed,painful,tender

-metastaticcervicalnode

fixed,painless,non-tender,hard-lymphoma(solitary/multiple;uni/bilateral)

fixed,painless,non-tender,rubber/firmFindtheoriginRef.1MassoftheNeck

Findtheorigin:

-Infection:lymphoidhyperplasia:acutelymphadenitisInfectionsource-pericoronitis(thirdmolar)-infectedcyst

-metastaticcervicalnodePrimarytumor–oralSCC,NPC,others-lymphoma(solitary/multiple;uni/bilateral)History,biopsy,

imagingexamination

Ref.2MassoftheNeckMassofspecificlocation

Massesinsubmandibularregion

Submandibularspaceinfection(cellulitis)Pericoronitis(thirdmolar),infectedcyst

Submandibularglandinfection(sialadenitis)

Pain&swellingpriortoeatingSubmandibularglandneoplasm

Biopsy,imagingexamination(sialography,CT)Ref.1MassoftheNeckMassofspecificlocation(觸診)

Massesinparotidregion

Enlarged

lymphnodes-Infection:lymphoidhyperplasia

movable,painless,non-tender

:acutelymphadenitis

movable/fixed,painful,tender

-metastaticcervicalnode

fixed,painless,non-tender,hard-lymphoma(solitary/multiple;uni/bilateral)

fixed,painless,non-tender,rubber/firmLocatetheoriginRef.1MassoftheNeck

Locatetheorigin:

-Infection:lymphoidhyperplasia:acutelymphadenitisInfectionsource-infectedcyst(congenitalpreauricularcyst,sebaceouscyst)

-metastaticparotidnodePrimarytumor–oralSCC,NPC,others-lymphoma(solitary/multiple;uni/bilateral)Biopsy,

imagingexamination

Ref.2MassoftheNeckMassofspecificlocation

Massesinparotidregion

Parotidglandinfection(parotitis)

StoneinStensen’sduct,virus,bacteriaParotidglandneoplasmBenign(70%),malignant(30%)

Biopsy,imagingexamination(sialography,CT)BallinhandRefs.2,4,5MassoftheNeckMassofspecificlocation

Massesinparotidregion

Bilateralparotidenlargement

Mikulicz’sdiseaseBenignlymphoepitheliallesion(enlargementofparotid,lacrymalglands)Mickulicz’ssyndrome(非lymphoepitheliallesion)Associatedwithlymphoma,sarcoidosis,TB

Sjogren’ssyndromeXerostomia,conjunctivitis,rheumatoidarthritisMassoftheNeckBiparotidenlargementXerostomiaDryeyePrimarySjogrensyndromeSecondarySjogrensyndromeXerostomiaConjunctivitissiccaConnectivetissuedisease(auto-immunedisease)Ref.7MassoftheNeckGeneralData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.6MassoftheNeckChiefComplaintAswellingmassofR’tparotidareaRef.6MassoftheNeckPresentIllnessThis34y/omalehasfoundanoduleoverrightinfra-auricularareafor5~6years,whichwaspainlessandnospecialfeeling.So,hedidn’tpayattentionaboutit.RecentlyhewenttoLDCforfullmouthscaling,theLDCdentistnotedthisswelling.Accordingtohisstatement,hefeltitgrewlargerandtendernessrecently.So,hecometoourOPDforfurtherevaluationandtreatment.MassoftheNeckPersonalHistoryAlcohol(-)

Betelquid(-)Smoking(-)

DeniedotherspecialhabitsMassoftheNeckPastHistoryPastMedicalHistory

Deniedanysystemicdisease

Drugallergy(+):unknown

PastDentalHistory

OD

Prosthesis

ToothExtraction

FullmouthscalingMassoftheNeckClinicalExaminationFluctuation:__

Pain:__Tenderness:+

Mobility:movableInduration:__

Lymphadenopathy:__Extra-oralRef.6MassoftheNeckCTFindingsPetrouseffectRef.6FeaturesSuggestiveofBenignancyMovable(exceptpalate)Unattachedtoskinormucosa(exceptpalate)NoulcerationofskinormucosaSlowgrowthLongdurationNopainNofacialnervepalsy

FeaturesSuggestiveofMalignancyIndurationFixedtooverlyingskinormucosaUlcerationofskinormucosaRapidgrowth;GrowthspurtShortdurationPain,oftensevereFacialnervepalsyRef.6Infectionor

Benign/MalignantPain(-)

Growingslowly(5~6years)Smoothsurface

CTfindings:demarcatedmarginNootherstructuredestructionMassoftheNeckBenignTumorWorkingDiagnosesPleomorphicAdenoma

Warthin’sTumor

BasalCellAdenoma

OncocytomaMassoftheNeckMassoftheNeckPleomorphicAdenoma53%~77%ofparotidtumors

Painless,slowgrowing,firmmassFacialpalsy&painarerare

Age:30~50y/o

SlightfemalepredilectionWarthin’sTumor

Occursalmostexclusivelyintheparotidgland

5%~14%ofparotidtumorsSlow-growing,nodularmass

FirmtofluctuanttopalpationBilateraloccurrence(5-14%)

Age:olderadults,51-70y/oAssociatedwithsmoking

MassoftheNeckMassoftheNeckBasalCellAdenomaParotid(75%)1st,minorglands2nd(esp.upperlip,buccalmucosa)

Age:middle-aged、olderadults、61~70(most)Sexpredilection:female(female:male=2:1insomestudy)

Slowgrowing,freelymovablemass,similartopleomorphicadenomaMosttumorsarelessthan3cmindiameter

1%ofallsalivaryglandtumorOncocytomaPainless,slowgrowing,

Firmmassrarely>4cm80%inparotidgland

Olderadults,71~80(peak)Slightfemalepredilection

Occurrence:<1%ofallsalivaryglandtumorMassoftheNeckPleomorphicAdenoma,rightparotidglandClinicalImpressionMassoftheNeckMassoftheNeckExcisionalBiopsyRef.6MassoftheNeckExcisionalBiopsyRef.6MassoftheNeckExcisionalBiopsyRef.6MassoftheNeckExcisionalBiopsyRef.6PleomorphicadenomaRtparotidglandMassoftheNeckHistopathological

DiagnosisRef.2MassoftheNeckMassofspecificlocation

Massesinmedian-paramedianregion

Submentallymphnodes:enlargement-Infection:lymphoidhyperplasia:acutelymphadenitis-metastaticcervicalnode-lymphoma

Epidermoidanddermoidcyst-DonothavetongueelevationRef.1(主要)MassoftheNeckMassofspecificlocation

Massesinmedian-paramedianregion

Thyroidglandinfection-thyroiditis

Acutesuppurativeinflammation,iodine-Hasimoto’sdisease

Autoimmunedisease,sensitivetoitsownthyroglobulin

Ref.1MassoftheNeckMassofspecificlocation

Massesinmedian-paramedianregion

Thyroglossalductcyst-Arisefromremnantsofembryonicthyroglossalductfromtonguebasetosternum-Upwardthrustwhenprotrudethetongue-Mostcommonlyoccursbelowhyoidbone-Dome-shaped(主要)Ref.1MassoftheNeckMassofspecificlocation

Massesinmedian-paramedianregion

Riedel’sthyroiditis-Afixed&hardmass-MimickingamalignancyThyroidneoplasm(withinthyroidgland)-Benign&malignanttumor-CystRef.1MassoftheNeckD.D.of

massesinmedian-paramedianregion

6.Ectopicthyroidgland1.Thyroglossalductcyst2.Epidermoid/dermoidcyst3.Submentallymphadenitis4.Submentalabscess5.ThyroidglandtumorRef.3MassoftheNeck6.Ectopicthyroidgland(Fig.below).Ref.7MassoftheNeck1.Intrathoracicgoiter2.Esophagealfibroma4.Sarcoidosis3.MetastaticcarcinomaLateralregion(low-level)Ref.3MassoftheNeck3.Carotidbo