IN THE NAME OF GOD

1. IN THE NAME OF GOD

2. Evaluation and Management of the Patient with a Neck Mass Dr.mirvakili Shahid sadoghi university

3. definition The general definition of a neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles.

4. Anatomy • Prominent landmarks • Hyoid bone • Thyroid cartilage (men) • Cricoid cartilage (women) • Trachea • Sternocleidomastoid muscle

5. Anatomy • Triangles of the neck • Anterior • Anterior border of the SCM, midline, lower border of the mandible • Subdivisions: inferior carotid, superior carotid, submandibular, submental • Posterior • Posterior border of SCM, clavicle, anterior border of trapezius • Subdivisions: subclavian, occipital

6. General Considerations • Patient age • Pediatric (0 – 15 years): 90% benign • Young adult (16 – 40 years): similar to pediatric • Late adult (>40 years): “rule of 80s” • Location • Congenital masses: consistent in location • Metastatic masses: key to primary lesion

7. General Considerations • Location of mass • Congenital and developmental consistent • Metastatic masses - help identify possible primary • Treat each case individually *

9. Diagnostic Steps • History • Careful and complete • Developmental time course • Associated symptoms (dysphagia, otalgia, hoarseness) • Personal habits (smoking, alcohol) • Prior trauma, irradiation or surgery

10. Diagnostic Steps • Physical Examination • Complete head and neck exam • Visualize all mucosal surfaces (direct, indirect) • Palpate oral and pharyngeal surfaces • Emphasize location, mobility and consistency of neck mass (vascular, salivary, nodal, inflammatory, congenital, neoplastic)

11. Empirical Antibiotics • Inflammatory mass suspected • Two week trial of antibiotics • Follow-up for further investigation

12. Diagnostic Tests • Fine needle aspiration biopsy (FNAB) • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Ultrasonography • Radionucleotide scanning • PET scan

13. Diagnostic Studies • Fine needle aspiration biopsy (FNAB) • Standard of care • Indications • Not obvious abscess • Persists following antibiotics • No contraindications (vascular?) • Fine gauge needle (23 - 27) • Skilled pathologist critical

14. Diagnostic Studies • FNAB continued • Needle track seeding not a concern • Bleeding complications reduced • Can be performed in children • Separates neoplasm from inflammatory & carcinoma from lymphoma • Minimum of four separate needle passes

15. Diagnostic Studies • Computed Tomography (CT) • Very helpful tool • Solid versus cystic • With contrast delineates vascularity • Metastatic masses • Unknown primary and staging purposes • Lucent changes, >1.5 cm, loss of sharpness • Avoid contrast in thyroid masses

16. Diagnostic Studies • Magnetic Resonance Imaging (MRI) • Similar information as CT • Better for upper neck and skull base • Infusion may substitute for arteriography

17. Diagnostic Studies • Ultrasonography • Less important with advent of FNAB • Useful for solid versus cystic (congenital cyst vs. lymph node/glandular tumor) • Noninvasive (pediatric)

18. Diagnostic Studies • Radionucleotide Scanning • Intra-glandular versus extra-glandular • Functionality • Salivary and thyroid masses • FNAB preferred for thyroid nodules • Solitary thyroid nodule • Multinodular goiter with new increasing nodule • Hashimoto’s with new nodule

19. Radionucleotide Scanning

20. PET scan • Pet scan indicates the functional activity of a mass • A more radio-intense mass has greater metabolic activity and is usually neoplastic • High false positive rate(warthin,s tumor)

22. Nodal Mass Workup in the Adult • Any solid asymmetric mass must be considered metastatic until proven otherwise • Presenting symptom in 12% of cancers • 80% are SCCa • History of smoking and alcohol worrisome • Suspicious symptoms and signs • Ipsilateral otalgia with normal otoscopy • Unilateral serous otitis media (nasopharynx)

23. Nodal Mass Workup in the Adult • Indications for panendoscopy • Positive FNAB (staging, search for primary, synchronous primaries - 10 to 20%) • Equivocal or negative FNAB in high risk • Unknown primary • Biopsy suspicious observed areas or suspicious abnormalities on CT/MRI • None - biopsy nasopharynx, tonsil (ipsilateral tonsillectomy for jugulodigastric nodes), base of tongue, and pyriform sinuses

24. Nodal Mass & Unknown Primary • Open excisional biopsy • Repeated exam and workup fail to reveal 10 with an equivocal or negative FNAB • 5% of the time • Prepare for complete neck dissection • Frozen section results • Inflammatory or granulomatous: culture tissue • Adenocarcinoma or lymphoma: close wound

25. Thyroid Masses Lymphoma Salivary Tumors Lipoma Carotid Body and Glomus Tumors Neurogenic Tumors Common Primary Tumors

26. Thyroid Masses • A leading cause of anterior neck masses • Children • Most common neoplastic condition • Male predominance • Greater chance of malignancy • Adults • Mostly benign • Female predominance

27. Thyroid Masses • Lymph node metastatic • 15% of papillary carcinomas • 40% with malignant nodules • Histologically in >90% (microscopic) • FNAB is standard of care • Decreases # of patients with surgery • Increases # of malignant tumors found at surgery • Doubles # of cases followed up • Repeat negative aspiration in 1 month

28. Rational approach to Management of a Thyroid nodule

29. Lymphoma • More common in pediatric & young adults • 80% of children with Hodgkin’s have neck mass • Signs and symptoms • Mass only, fever, hepatosplenomegaly, diffuse adenopathy • FNAB - 1st line; open biopsy if suggestive • CT scans (H&N, chest, abdomen) & bone marrow biopsy

30. Salivary Tumors • Any preauricular enlarging mass or at the angle of the mandible is suspicious • Benign - asymptomatic • Metastatic - rapid growth, skin fixation or cranial nerve palsies • Open excisional biopsy preferred

31. Salivary Tumors • FNAB • Reduces # of patients with surgery by 1/3 • Distinguishes intra-glandular lymph nodes, localized sialadenitis, benign cysts • Accuracy >90% (better for benign) • Sensitivity - 90%; Specificity - 80% • May facilitate surgical planning or patient counseling • Prepare for total parotidectomy & nerve sacrifice in unknown primaries

32. Carotid Body and Glomus Tumor • Rare in the pediatric population • Classical presentation • Adult • Pulsatile, compressible mass at carotid bifurcation • Mobile side to side • Diagnosis confirmed by angiography or CT

33. Carotid Body and Glomus Tumor • Treatment • Elderly adult • Observation • Irradiation to arrest growth • Young adult • Resection of small tumors • Hypotensive anesthesia • Preoperative embolization and measurement of catecholamines release

34. Lipoma • Over age 35 usually • Ill-defined, soft masses • Diagnosis confirmed by excisional biopsy

35. Neurogenic Tumors • Peripheral nervous system tumors • Arise from neural crest derivatives • Include schwannomas, neurofibromas and malignant peripheral nerve sheath tumors • Increased incidence in NF syndromes • Schwannomas occur most commonly • MPNST uncommon in head and neck

36. Neurogenic Tumors • Schwannoma • Benign • Any age, but most common 20 to 50 years • Solitary, slowly enlarging, painless mass • Medial tonsillar displacement • Hoarseness (vagus nerve) • Horner’s (sympathetic chain) • Surgical excision is treatment of choice

37. Congenital and Developmental Masses • Epidermal and Sebaceous cysts • Branchial Cleft Cysts • Thyroglossal Duct Cysts • Vascular Tumors

38. Epidermal and Sebaceous Cysts • Most common congenital mass • Older age group most often • Clinical diagnosis - movement and elevation of overlying skin • Excisional biopsy confirms

39. Branchial Cleft Cysts • Late childhood or early adulthood • Often appears rapidly after URI • Skin erythema and tenderness after recent infection • May express purulent material if sinus tract is present • Treatment is initial control of infection, followed by surgical excision

40. Branchial Cleft Cysts • 1st branchial cleft cyst • 2nd most common • Inferior or angle of the mandible or below the ear lobe • Close association with facial nerve possible • Excision may require total parotidectomy and facial nerve dissection

41. Branchial Cleft Cysts • 2nd branchial cleft cyst • Most common • Underlying SCM • Tract courses medial over 12th nerve and between internal and external carotids • 3rd and 4th branchial cleft cysts • Rarely reported

42. Thyroglossal Duct Cysts • Most common congenital neck mass • Midline or near-midline mass • Elevates on swallowing or protrusion of the tongue • Differential: lymph nodes, dermoids, ectopic thyroid tissue • Surgical removal (Sistrunk) after resolution of infection

43. Vascular Tumors • Almost always present within 1st year • CT/MRI help in diagnosis and defining extent of lesion • Lymphangioma • Remain unchanged into adulthood • Soft, doughy, ill-defined • Treatment: excision for easily accessible or vital function compromise

44. Vascular Tumors • Hemangiomas • Most often resolve spontaneously • Bluish, compressible • Surgical treatment • Rapid growth • Associated thrombocytopenia • Involvement of vital structures • After failure of medical therapy

45. Inflammatory Disorders • Lymphadenitis • Granulomatous lymphadenitis

46. Lymphadenitis • Very common, especially during 1st decade • Marked tenderness, torticollis, trismus, and dysphagia • Systemic signs of infection • Initial treatment - directed antibiotics • Close follow up

47. Lymphadenopathy • Failure of antibiotics necessitates biopsy after complete head and neck work-up • FNAB indications • Progressively enlarging nodes • Solitary, asymmetric nodal mass • Supraclavicular mass • Persistent nodes without infectious signs

48. Lymphadenopathy • Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out lymphoma or granulomatous disease

49. Granulomatous Lymphadenitis • Develop over weeks and months • Minimal systemic complaints or findings • Firm glands, fixation and injection of skin • Common etiologies • Typical Mycobacterium tuberculosis (adults) • Atypical Mycobacterium tuberculosis (children) • Cat-scratch fever (Bartonella henselae) (children) • Actinomycosis, Sarcoidosis

50. Granulomatous Lymphadenitis • Atypical TB • Anterior triangle lymph nodes • Brawny skin, induration and pain • Usually responds to complete surgical excision • Cat-scratch fever • Preauricular or submandibular lymph nodes • Spontaneous resolution 1-2 months • Typical TB (rarely seen, posterior nodes)