Unit II

1. Unit II Head and Neck Masses Matthew Bromwich, MD, FRCSC

2. Objectives • List the components that are required to adequately describe a neck mass. • Identify the lymphatic drainage of the oral cavity and oropharynx. • Compare and contrast the features of an inflammatory/infectious neck mass, a benign neck mass and a malignant neck mass. • Compare and contrast the differential diagnosis of a neck mass in the pediatric vs the adult population. • Provide a differential diagnosis of a midline and a lateral neck mass. • Describe the embryology of branchial cleft cysts and sinuses and their location in the head and neck. (GET A GOOD BOOK! – This is hard to explain in class) • Recognize the utility of a fine needle aspiration biopsy in obtaining the pathological diagnosis of a neck mass. [Unit name – Lecture title – Prof name]

3. Description List the components that are required to adequately describe a neck mass.

4. Describing a Mass • History • Onset, Duration, Pain, Associated • Growth Rate/Direction • Inspection • Location • Color/Inflammation/Skin Change • Drainage • Palpation • Size, Shape • Consistency (Hard, Rubbery, Soft) • Delimitation (Matted/Single) • Fluctuance • Pain (Non-tender, Tender) • Temperature (Hot) • Mobility (Fixed/Invading) • Pulsatile

5. Triangles of Neck - Location Submental

6. Lymphatic Drainage Identify the lymphatic drainage of the oral cavity and oropharynx.

7. Lymphatic Chains /Facial Pre-auricular/ Anterior/ Submental/

8. Lymph Nodes Levels II I III Level VI VI V IV SC

9. Lymphatic Drainage: Oral Tongue • Oral tongue drains to either level 1,2 or 3 depending on location and depth Contra Ipsi

10. Lymphatic Drainage: Tongue Base Tongue Base - Bilateral drainage to level II

11. Lymphatic Drainage: Nasopharynx Nasopharynx - Bilateral drainage to levels II,V and retropharyngeal nodes

12. Larynx • Laryngeal Cancers drain to level II and III

13. Summary: Lymphatic Drainage [Unit name – Lecture title – Prof name]

14. Characteristics Compare and contrast the features of an inflammatory/infectious neck mass, a benign neck mass and a malignant neck mass.

15. Differentiating Characteristics of a Mass • Consider patient age (Young=benign, Old=Malignant) • Consider history • New onsent, enlarging slowly, sudden • Associated symptoms (dysphagia, dysphonia, ear pain, numbness, weakness) Characteristics of lymph nodes [Unit name – Lecture title – Prof name]

16. Differential Diagnosis Compare and contrast the differential diagnosis of a neck mass in the pediatric vs the adult population.

17. Differential Diagnosis (VINDICATED) – of H/N masses • C – Congenital • Lateral • Medial • Variable • V – Vascular • Arterial • Venous • Lymphatic • Capillary • I – Infectious/Inflammatory • Bacterial • Viral • Fungal • N – Neoplastic • Benign • Malignant Common cause of a Neck Mass Uncommon cause of a Neck Mass • D – Degenerative • I – Idiopathic • A – Autoimmune • T – Trauma • E – Endocrine • D - Drug [Unit name – Lecture title – Prof name]

18. Common Neck Masses – Etiological Congenital vs Acquired Congenital • Midline • Thyro-glossal duct cysts • Dermoid cysts • Teratoma • Lateral • Branchial cleft cysts • Laryngocele • Thymiccysts • Variable • Vascular Malformations (Lymphatic/Venous/Arterial/Capillary) Infectious • Lymphadenopathy • Bacterial • Viral • Granulomatous • Tuberculous • Cat-scratch • Fungal • Sarcoidosis • Thyroiditis • Sialadenitis • Parotid • Submaxillary Neoplastic • Unknown primary • Benign • Hemangioma • Thymoma • Thyroid Goitre • Lipoma • Salivary (Plemorphic Adenoma)Schwannoma • Malignant • SCC,BCC • Melanoma • Salivary (Adenocarcinoma) • Thyroid (Papillary) • Lymphoma • Glomustumor • Rhabdomyosarcoma [Unit name – Lecture title – Prof name]

19. Impact of Age on Differential: [Unit name – Lecture title – Prof name]

20. Pediatric Neck Mass [Unit name – Lecture title – Prof name]

21. Frequency of Diagnosis % pediatric lesions which which present as a neck mass (Torsiglieri et al., 1988)

22. Malignant Lesions - Children • 5% of all malignancies are in children • Greater than 50% are lymphomas or soft tissue sarcomas • Under 6 years old • Neuroblastoma, non-Hodgkins lymphoma, rhabdomyosarcoma • 7 to 13 years old • Hodgkins/non-Hodgkins, thyroid carcinoma, rhabdomyosarcoma • Adolescents • Hodgkins lymphoma

23. Midline and LateralNeck Lesions Provide a differential diagnosis of a midline and a lateral neck mass.

24. Neck Mass - Location Lymphatic Malformation

25. Thyroglossal Duct Cyst (Midline - Congenital)

26. Thyroglossal Duct Remnants - Sistrunk Moir 2004

27. Atypical Mycobacterium (Lateral – Infectious) • Painless, No fever, stable, weeks-months in duration • Rx – Biaxin/Rifampin and surgical excision • DDx (Granulomatous Disease) • TB • Fungal • Cat Scratch • Sarcoid

28. Cervical Adenitis (Inflammatory – Variable) • Mostly usual bacterial • Moraxella Catarrhalis • Strep pneumo • H-Flu • Fever, Ill, neck mass, tender • Rx antibiotics • Rx IV antibiotics *48hr • US or CT +/- I+D

29. Branchial Arches Describe the embryology of branchial cleft cysts and sinuses and their location in the head and neck.

30. What the heck is a branchial arch? [Unit name – Lecture title – Prof name]

31. Branchial Cleft Anomalies Cyst Sinus Fistula Schroeder. 2007

32. Branchial Embryology • Ectoderm, mesoderm, endoderm • Incomplete closure may result in branchial cleft anomalies

34. Cartilages (Arch Made from Mesoderm) Reicherts’s Meckel’s Thyroid Cricoid [Unit name – Lecture title – Prof name]

36. 1st Branchial Cleft Anomalies • Type I • Ectodermal duplication of EAC • Open medial, inferior or posterior to conchal cartilage • Type II • Includes Mesoderm • Open in anterior neck, superior to hyoid bone • Course over mandible through parotid • Variable relationship to VII

37. 2nd Branchial Arch Anomalies Moir. 2004

38. 2nd and 3rd Branchial Arch Anomalies

39. Review: Type I,II, III Branchial Cleft Cysts Adult Anatomy Embryology [Unit name – Lecture title – Prof name]

40. Adult Neck Mass

41. Malignant Lesions – Adults (HN Ca = 6% of all CA) • Head and neck • SCC (90% of Head and neck Ca) • BCC (most common skin Ca) • Thyroid Ca – (1% of all new cancer - Papillary) • Salivary Ca (Muco-epidermoid, AdenoCa, Acinic) • Sarcoma (1% of all HN Ca)

42. 1) Lymph Node • Posterior Triangle? • Metastatic Skin Ca. SCC. [Unit name – Lecture title – Prof name]

43. 2) Anterior Triangle • Floor of mouth, Larynx? • Likely SCC • Primary found on pan endoscopy [Unit name – Lecture title – Prof name]

44. 3) No Neck nodes – just a facial mass • Facial Mass • Parotid Nodes (Forehead SCC) • Primary Salivary Tumor • Pleomorphic Adenoma • Adenoid Cystic • Schwannoma

45. FNA Recognize the utility of a fine needle aspiration biopsy in obtaining the pathological diagnosis of a neck mass.

46. FNA • When to use a FNA • Initial work up of a non-pulsatile mass to obtain tissue for the purposes of diagnosis • What a FNA will tell you • Tissue Diagnosis without open biopsy and hence prevent possible seeding of malignant lesions • Will differentiate Cystic/Solid • Microscopic Nuclear Features (papillary thyroid CA, SCC, Salivary neoplasms, TB) • There is often not enough material to perform flow cytometry • What a FNA will NOT tell you • Lymphoma (especially poor at non-hodgkin's lymphoma) • Tissue Architecture • Invasion (Angio-invasion seen in follicular thyroid ca) • Thyroid FNA (US/Uptake Scan/FNA) • FNA • Reported as benign, malignant (papillary), suspicious (follicular lesion - follicular carcinomas, follicular adenomas, and nodules of goiters ) or inconclusive • 90-95% sensitivity/specificity when conclusive [Unit name – Lecture title – Prof name]

47. Who Gets a FNA vs some other kind of biopsy? • 1) Known prior SCC, new neck mass – nothing else to biopsy on head • 2) Unknown primary, new neck mass (will be doing an panendo) • 3) New facial mass in saliva gland – no other lesions – non smoker • Who doesn’t? A 6 year old girl with a 3cm neck mass present for 2 months which is painless firm and growing. She needs an excisional biopsy. 3 1 2 [Unit name – Lecture title – Prof name]