“Head & Neck Masses” a road map

1. “Head & Neck Masses” a road map Dr. Imtiaz M Qazi

2. Road map for diagnosis • History • Physical examination • Investigations • Differential Diagnosis • according to the cause • according to the site

3. D.D. according to the Cause:

4. D.D. according to the Site:

5. Road map for diagnosis • History • Physical examination • Investigations • Differential Diagnosis • according to the cause • according to the site

6. The history should be taken with the differential diagnosis in mind History For example: in younger pt. look for congenital lesions in older pt. the first concern would be neoplasia

7. Personal history :- • Age • Sex • race • Special habits: smoking, alcohol History • Present history :- • Onset, Course, Duration • Symptoms which indicate inflammatory process (fever, wt loss, night sweat) • Symptoms which indicate malignancy • Symptoms of hypo or hyperthyroidism

8. Head & Neck Symptoms • Compression Symptoms • Respiratory Symptoms • GI Symptoms History • Past history : • History of trauma or surgery • History of medication & radiation • History of travel Family history

9. Road map for diagnosis • History • Physical examination • Investigations • Differential Diagnosis • according to the cause • according to the site

10. Examination is challenging as the area to be examined is not easily visualized • General Examination : • General appearance of the patient. • Vital Signs. Examination • Local Examination : • Head & Neck Examination • Examination of the mass

11. Head & Neck Examination 1. Look at the head & neck for any mass or ulcer Examination 2. Examine L.N.

12. 3. Examine thyroid Examination 4. Examine ear, nose & throat

13. 5. Examine oral cavity Examination 6. Indirect laryngoscope 7. Panendoscopy (in occult primary)

14. Examination of the mass 1. Inspection : a. site b. shape c. color d. relation to deglutition e. relation to tongue protrusion 2. Palpation : a. temperature b. tenderness c. size d. surface e. edge f. consistency g. fluctuation h. pulsatility i. relation to overlying skin j. mobility k. relation to underlying structures Examination 3. Percussion : on the sternum for retrosternal extension of the thyroid 4. Auscultation : for bruits (with vascular mass)

15. Road map for diagnosis • History • Physical examination • Investigations • Differential Diagnosis • according to the cause • according to the site

16. Investigations • Routine • Diagnostic Investigation

17. Routine: 1. CBC :( infection, lymphoma ……..etc. ) 2. UR :( Parathyroid ) 3. TFT :( Thyroid ) 4. PTH :( Parathyroid ) 5. Tuberculin test :( T.B. ) 6. CXR :( Lung lesions ) Investigation

18. Diagnostic: • USG (Ultrasonography) • CT (Computed Tomography) with contrast • MRI (Magnetic Resonance Imaging) • FNAC (Fine Needle Aspiration Cytology) • Radionucleotide Scanning • Open biopsy

19. USG - Ultrasonography It is sometimes useful in differentiating solid from cystic masses. However, with the current accuracy of FNAC, this study has become less important in the work-up of the neck mass.

20. CT - Computed Tomography • It can distinguish cystic from solidlesions • Define the origin and full extent of • deep, ill-defined masses • The contrast can delineate vascularity • or blood flow • In patients with metastatic SCC to • the neck from an unknown primary, • CT should be obtained to detect an • unknown primary lesion • To help with staging purposes.

21. MRI - Magnetic Resonance Imaging • It is currently better for upper neck and skull base masses due to motion artifact on CT. • With contrast it is good for vascular delineation and may even substitute for arteriography in the pulsatile mass or mass with a bruit or thrill.

22. FNAC - Fine Needle Aspiration Cytology • FNAC is the STANDARD for diagnosis of neck masses. • Differentiates inflammatory from neoplastic lesions, either benign or malignant. • Differentiates carcinoma from lymphoma, which can prevent unnecessary panendoscopy.

23. Indications for FNA • Progressively enlarging nodes • A single asymmetric node • A persistent nodal mass without antecedent active signs of infection • Actively infectious condition that do not respond to conventional antibiotics

24. NO contraindications to FNAC • Pulsatile neck masses may represent a carotid body tumor, and although many clinicians prefer not to biopsy these lesions, the fine gauge of the needle reduces bleeding complications. • Needle-track seeding of tumor is not a concern with the fine needles used today. • FNAC can also be performed in children

25. Radionucleotide Scanning • Differentiate a mass from within a gland from one outside a glandular structure . • Also indicate the functionality of the mass. • This is particularly important for salivary and suspected thyroid gland masses.

26. Road map

27. Let’s applythe Road mapto a case

28. Personal history : • 47 yrs old female pt. from Philippines She is housewife,notsmoker or alcoholic C/O: Lt lateral neck swelling × 1 yr • Present history : • The condition started 1 yr ago with a gradual onset and progressive course of lt lateral neck mass at the lt supraclavicular region followed 6 months later by another mass at the upper part of the neck extending to the post-auricular region, not painful or tender • No fever, night sweat or symptoms which indicate inflammatory process History

29. No Dysphagia, Dyspnoea, hoarseness of voice or other compression Symptoms • No Symptoms of hypo or hyperthyroidism • No nasal or respiratory Symptoms • No GI Symptoms History • Past history : • Hx of Lt mastectomy on 2005 for breast cancer then received chemoradiotherapy for 1 yr • Family history • No family hx of similar condition • Father is hypertensive

30. General Examination • Pt appears well, conscious and oriented to time and place. • Vital Signs are normal. Examination • Local Examination : • Head & Neck Examination • Examination of the mass

31. Head & Neck Examination Lt lateral neck mass at the left supraclavicular region and at the upper part of the neck extending to the post-auricular region. Examination

32. Palpation of the mass: • temperature: not hot • Pain: not painful • tenderness: not tender • size: 2 * 4 cm • consistency: hard • fluctuation: no fluctuation • pulsatility: not pulsating • Mobility: fixed • relation to overlying skin: adherent to the skin • relation to underlying structures: fixed Examination

33. L.N: • Palpable: • Post auricular • upper deep cx • supraclavicular LN • LNs are firm, fixed to the surrounding tissue and to the overlying skin. Examination

34. Thyroid: • NAD Examination Ear, Nose & Throat: • NAD

35. Mouth cavity: Dental caries with Hx of dental extraction after radiotherapy Examination Indirect laryngoscope: • NAD

36. Investigations • Routine • Diagnostic Investigation

37. Routine: • CBC : • 2. UR : • 3. TFT : • 4. PTH : • 5. Tuberculin test : • 6. CXR : Normal Investigation

38. Diagnostic: • USG: • Solid not cystic swelling

39. CT • Normal nasopharynx

43. MRI

44. FNAC Lt sided upper cervical LN with ? metastatic breast carcinoma for panendoscopy/Biopsy

45. Excision biopsy

46. Panendoscopy • Nose: NAD (apart from nasal allergy and DNS to the Rt) • PNS: NAD • Oral cavity: NAD • Tongue: NAD • Larynx: NAD • Pyriform sinus: NAD • Post cricoid area: NAD • Upper oesophageal end: NAD

47. D.D. according to the cause:

48. D.D. according to the site:

49. Management Chemoradiotherapy

50. Road map