Evaluation and Management of the Patient with a Neck Mass

1. 1 Evaluation and Management of the Patient with a Neck Mass Michael P. Underbrink, MD Byron J. Bailey, MD December 12, 2001

2. 2 Introduction Common clinical finding Patients of all age groups Extremely complex differential diagnoses Systemic approach essential

3. 3 Anatomy Prominent landmarks Hyoid bone Thyroid cartilage (men) Cricoid cartilage (women) Trachea Sternocleidomastoid muscle

4. 4 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

5. 5 Anatomy Lymphatic levels Predictable pattern of flow Level I (submental & submandibular nodes) Level II - IV (jugulodigastric nodes) Level V (spinal accessory & transverse cervical nodes) - *supraclavicular Level VI (pre/paratracheal, precricoid, and perithyroidal nodes)

6. 6 General Considerations Age Groups Pediatric (0 to 15 years): 90% benign Young adult (16 to 40 years): similar to children Late adult (>40 years): �rule of 80�

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

8. 8 Diagnostic Steps History Careful and complete Developmental time course Associated symptoms (dysphagia, otalgia, hoarseness) Personal habits (smoking, alcohol) Prior trauma, irradiation or surgery

9. 9 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)

10. 10 Clinical Antibiotic Trial With a suspicion of inflammatory adenopathy and negative exam 2 week trial of directed antibiotic therapy Close follow up

11. 11 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

12. 12 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

13. 13 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

14. 14 Diagnostic Studies Magnetic Resonance Imaging (MRI) Similar information as CT Better for upper neck and skull base Infusion may substitute for arteriography

15. 15 Diagnostic Studies Ultrasonography Less important with advent of FNAB Useful for solid versus cystic (congenital cyst vs. lymph node/glandular tumor) Noninvasive (pediatric)

16. 16 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

17. 17 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)

18. 18 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

19. 19 Nodal Mass & Unknown Primary University of Florida study, 2001 Primary detected ~40% of the time 80% in base of tongue or tonsil No suggestive findings on exam or CT/MRI decreased yield to 18%

20. 20 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

21. 21 Common Primary Tumors Thyroid Masses Lymphoma Salivary Tumors Lipoma Carotid Body and Glomus Tumors Neurogenic Tumors

22. 22 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

23. 23 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

24. 24 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

25. 25 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

26. 26 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

27. 27 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

28. 28 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

29. 29 Lipoma Over age 35 usually Ill-defined, soft masses Diagnosis confirmed by excisional biopsy

30. 30 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

31. 31 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

32. 32 Congenital and Developmental Masses Epidermal and Sebaceous cysts Branchial Cleft Cysts Thyroglossal Duct Cysts Vascular Tumors

33. 33 Epidermal and Sebaceous Cysts Most common congenital mass Older age group most often Clinical diagnosis - movement and elevation of overlying skin Excisional biopsy confirms

34. 34 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

35. 35 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

36. 36 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

37. 37 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

38. 38 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

39. 39 Vascular Tumors Hemangiomas Most often resolve spontaneously Bluish, compressible Surgical treatment Rapid growth Associated thrombocytopenia Involvement of vital structures After failure of medical therapy

40. 40 Inflammatory Disorders Lymphadenitis Granulomatous lymphadenitis

41. 41 Lymphadenitis Very common, especially during 1st decade Marked tenderness, torticollis, trismus, and dysphagia Systemic signs of infection Initial treatment - directed antibiotics Close follow up

42. 42 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

43. 43 Lymphadenopathy Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out lymphoma or granulomatous disease

44. 44 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

45. 45 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)

46. 46 Summary Extensive differential diagnosis Thorough work-up needed FNAB invaluable Malignancy should never be overlooked Close follow-up and aggressive pursuit of a diagnosis essential

47. 47 Case #1 58 year old female presents with a near-midline anterior neck mass present for 2 months

48. 48 Case #1 History of thyroid problems following pregnancy 30 years ago, being treated with supplemental thyroid hormone History of HTN No previous thyroid cancer or irradiation Family history negative

49. 49 Case #1 Physical examination reveals a 2x2 cm, rubbery mass to the left of midline No palpable cervical adenopathy Labs: TSH, free thyroxine normal

50. 50 Case #1 FNAB revealed cellular aspirate of enlarged follicular cells forming microfollicles in a repetitive pattern - follicular tumor

51. 51 Case #1 A thyroid lobectomy was performed, and the histological pattern revealed follicular adenoma.

52. 52 Case #2 2 year-old child presents with a 4-week history of sore throat, fever, and cervical adenopathy.

53. 53 Case #2 The child has been treated with prior courses of cephalexin and amoxicillin for alternating periods of 7 to 10 days without any resolution of symptoms and worsening adenopathy.

54. 54 Case #2 PMHx - noncontributory NKDA SocHx - family has a outside cat, which has never scratched the child to their knowledge

55. 55 Case #2 Physical Examination reveals a 3x3 cm fluctuant, right preauricular lymph node which is mildly tender.

56. 56 Case #2 FNAB revealed numerous granulomas with intracellular bacilli in Warthin-Starry silver-staining.

57. 57 Case #2 The child was subsequently treated with a 10 day course of Azithromycin and the lymphadenopathy resolved in less than 4 weeks.