Evaluation and Management of the Patient with a Neck Mass

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Evaluation of the Neck Mass,Adapted from,Michael Underbrink, MD,Byron J. Bailey, MD,1,Introduction,Common clinical finding,All age groups,Very complex differential diagnosis,Systematic approach essential,2,3,Anatomical Considerations,Prominent landmarks,Triangles of the neck,Carotid bulb,Lymphatic levels,4,Anatomical Considerations,Prominent landmarks,Triangles of the neck,Carotid bulb,Lymphatic levels,5,Anatomical Considerations,Prominent landmarks,Triangles of the neck,Carotid bulb,Lymphatic levels,6,Anatomical Considerations,Prominent landmarks,Triangles of the neck,Carotid bulb,Lymphatic levels,7,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,8,Metastasis Location according to Various Primary,9,Risk Factors for Head and Neck Cancer,Chronic sun exposure,Tobacco and alcohol use,Poor dentition,Industrial or environmental exposures,Family history,10,Symptoms of Head and Neck Cancer,Nonhealing ulcer within the oral cavity or oropharynx,Persistent sore throat,Dysphagia,Change in voice,Recent weight loss,11,Diagnostic Steps,History,Developmental time course (age, size, acute vs chronic),Associated symptoms (fever, sore throat, cough, dysphagia, otalgia, voice),Personal habits (tobacco, alcohol),Recent travel, trauma, insect bites, pets/farm animals,Previous irradiation or surgery,12,Physical Exam,Complete head and neck exam,Skin, otologic examination, oropharynx, tongue,Ulcerations, submucosal swelling, or asymmetry, particularly in the tonsillar fossa,Examination of the larynx and pharynx is accomplished by indirect or flexible laryngoscopy.,Palpation during swallowing or during a Valsalvas maneuver may identify pathology within the larynx and thyroid gland.,Rotation of the head in both flexion and extension aids examination of the posterior triangle of the neck.,13,Empirical Antibiotics,Inflammatory mass suspected,Two week trial of broad spectrum antibiotics,Follow-up 1-2 weeks for further investigation,14,Diagnostic Tests,Fine needle aspiration biopsy (FNAB),Computed tomography (CT),Magnetic resonance imaging (MRI),Ultrasonography,Radionucleotide scanning,15,Fine Needle Aspiration Biopsy,Standard of diagnosis,Indications,Any neck mass that is not an obvious abscess,Persistence after a 2 week course of antibiotics,Progressive growth, supraclavicular, 3 cm,Any symptoms associated with lymphoma,Small gauge needle,Reduces bleeding,Seeding of tumor not a concern,No contraindications (vascular ?),16,Fine Needle Aspiration Biopsy,Proper collection required,Minimum of 4 separate passes,Skilled cytopathologist essential,On-site review best,17,Fine Needle Aspiration Biopsy,18,Computed Tomography,Distinguish cystic from solid,Extent of lesion,Vascularity (with contrast),Detection of unknown primary (metastatic),Pathologic node (lucent, 1.5cm, loss of shape),Avoid contrast in thyroid lesions,19,Computed Tomography,20,Magnetic Resonance Imaging,Similar information as CT,Better for upper neck and skull base,Vascular delineation with infusion,21,Magnetic Resonance Imaging,22,Ultrasonography,Less important now with FNAB,Solid versus cystic masses,Congenital cysts from solid nodes/tumors,Noninvasive (pediatric),23,Ultrasonography,YROID,ASS,24,Radionucleotide Scanning,Salivary and thyroid masses,Location glandular versus extra-glandular,Functional information,FNAB now preferred for for thyroid nodules,Solitary nodules,Multinodular goiter with new increasing nodule,Hashimotos with new nodule,25,Radionucleotide Scanning,26,Nodal Mass Workup in the Adult,Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise,Asymptomatic cervical mass 12% of cancer, 80% of these are SCCa,27,Nodal Mass Workup in the Adult,Ipsilateral otalgia with normal otoscopy direct attention to tonsil, tongue base, supraglottis and hypopharynx,Unilateral serous otitis direct examination of nasopharynx,28,Nodal Mass Workup in the Adult,Panendoscopy,FNAB positive with no primary on repeat exam,FNAB equivocal/negative in high risk patient,Directed Biopsy,All suspicious mucosal lesions,Areas of concern on CT/MRI,None observed nasopharynx, tonsil (ipsilateral tonsillectomy for jugulodigastric nodes), base of tongue and piriforms,Synchronous primaries (10 to 20%),29,Nodal Mass Workup in the Adult,Open excisional biopsy,Only if complete workup negative,Occurs in 5% of patients,Be prepared for a complete neck dissection,Frozen section results (complete node excision),Inflammatory or granulomatous culture,Lymphoma or adenocarcinoma close wound,30,31,Primary Tumors,Thyroid mass,Lymphoma,Salivary tumors,Lipoma,Carotid body and glomus tumors,Neurogenic tumors,32,Thyroid Masses,Leading cause of anterior neck masses,Children,Most common neoplastic condition,Male predominance,Higher incidence of malignancy,Adults,Female predominance,Mostly benign,33,Thyroid Masses,Lymph node metastasis,Initial symptom in 15% of papillary carcinomas,40% with malignant nodules,Histologically (microscopic) in 90%,FNAB has replaced USG and radionucleotide scanning,Decreases # of patients with surgery,Increased # of malignant tumors found at surgery,Doubled the # of cases followed up,Unsatisfactory aspirate repeat in 1 month,34,Thyroid Masses,35,Lymphoma,More common in children and young adults,Up to 80% of children with Hodgkins have a neck mass,Signs and symptoms,Lateral neck mass only (discrete, rubbery, nontender),Fever,Hepatosplenomegaly,Diffuse adenopathy,36,Lymphoma,FNAB first line diagnostic test,If suggestive of lymphoma open biopsy,Full workup CT scans of chest, abdomen, head and neck; bone marrow biopsy,37,Lymphoma,38,Salivary Gland Tumors,Enlarging mass anterior/inferior to ear or at the mandible angle is suspect,Benign,Asymptomatic except for mass,Malignant,Rapid growth, skin fixation, cranial nerve palsies,39,Salivary Gland Tumors,Diagnostic tests,Open excisional biopsy (submandibulectomy or parotidectomy) preferred,FNAB,Shown to reduce surgery by 1/3 in some studies,Delineates intra-glandular lymph node, localized sialadenitis or benign lymphoepithelial cysts,May facilitate surgical planning and patient counseling,Accuracy 90% (sensitivity: 90%; specificity: 80%),CT/MRI deep lobe tumors, intra vs. extra-parotid,Be prepared for total parotidectomy with possible facial nerve sacrifice,40,Salivary Gland Tumors,41,Carotid Body Tumor,Rare in children,Pulsatile, compressible mass,Mobile medial/lateral,not,superior/inferior,Clinical diagnosis, confirmed by angiogram or CT,Treatment,Irradiation or close observation in the elderly,Surgical resection for small tumors in young patients,Hypotensive anesthesia,Preoperative measurement of catecholamines,42,Carotid Body Tumor,43,Lipoma,Soft, ill-defined mass,Usually 35 years of age,Asymptomatic,Clinical diagnosis confirmed by excision,44,Lipoma,45,Neurogenic Tumors,Arise from neural crest derivatives,Include schwannoma, neurofibroma, and malignant peripheral nerve sheath tumor,Increased incidence in NF syndromes,Schwannoma most common in head & neck,46,Schwannoma,Sporadic cases mostly,25 to 45% in neck when extracranial,Most commonly between 20 and 50 years,Usually mid-neck in poststyloid compartment,Signs and symptoms,Medial tonsillar displacement,Hoarseness (vagus nerve),Horners syndrome (sympathetic chain),47,Schwannoma,48,Congenital and Developmental Mass,Epidermal and sebaceous cysts,Branchial cleft cysts,Thyroglossal duct cyst,Vascular tumors,49,Epidermal and Sebaceous Cysts,Most common congenital/developmental mass,Older age groups,Clinical diagnosis,Elevation and movement of overlying skin,Skin dimple or pore,Excisional biopsy confirms,50,Epidermal and Sebaceous Cysts,51,Branchial Cleft Cysts,Branchial cleft anomalies,2,nd,cleft most common (95%) tract medial to cnXII between internal and external carotids,1,st,cleft less common close association with facial nerve possible,3,rd,and 4,th,clefts rarely reported,Present in older children or young adults often following URI,52,Branchial Cleft Cysts,Most common as smooth, fluctuant mass underlying the SCM,Skin erythema and tenderness if infected,Treatment,Initial control of infection,Surgical excision, including tract,May necessitate a total parotidectomy (1,st,cleft),53,Branchial Cleft Cysts,54,Thyroglossal Duct Cyst,Most common congenital neck mass (70%),50% present before age 20,Midline (75%) or near midline (25%),Usually just inferior to hyoid bone (65%),Elevates on swallowing/protrusion of tongue,Treatment is surgical removal (Sis trunk) after resolution of any infection,55,Thyroglossal Duct Cyst,56,Vascular Tumors,Lymphangiomas and hemangiomas,Usually within 1,st,year of life,Hemangiomas often resolve spontaneously, while lymphangiomas remain unchanged,CT/MRI may help define extent of disease,57,Vascular Tumors,Treatment,Lymphangioma surgical excision for easily accessible or lesions affecting vital functions; recurrence is common,Hemangiomas surgical excision reserved for those with rapid growth involving vital structures or associated thrombocytopenia that fails medical therapy (steroids, interferon),58,Vascular Tumors (lymphangioma),59,Vascular Tumors (hemangioma),60,Inflammatory Disorders,Lymphadenitis,Granulomatous lymphadenitis,61,Lymphadenitis,Very common, especially within 1,st,decade,Tender node with signs of systemic infection,Directed antibiotic therapy with follow-up,FNAB indications (pediatric),Actively infectious condition with no response,Progressively enlarging,Solitary and asymmetric nodal mass,Supraclavicular mass (60% malignancy),Persistent nodal mass without active infection,62,Lymphadenopathy,Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease,63,Granulomatous lymphadenitis,Infection develops over weeks to months,Minimal systemic complaints or findings,Common etiologies,TB, atypical TB, cat-scratch fever, actinomycosis, sarcoidosis,Firm, relatively fixed node with injection of skin,64,Granulomatous lymphadenitis,Typical,M. tuberculosis,More common in adults,Posterior triangle nodes,Rarely seen in our population,Usually responds to anti-TB medications,May require excisional biopsy for further workup,65,Granulomatous lymphadenitis,Atypical,M. tuberculosis,Pediatric age groups,Anterior triangle nodes,Brawny skin, induration and pain,Usually responds to complete surgical excision or curettage,66,Granulomatous lymphadenitis,Cat-scratch fever (,Bartonella,),Pediatric group,Preauricular and submandibular nodes,Spontaneous resolution with or without antibiotics,67,Granulomatous lymphadenitis,68,Summary,Extensive differential diagnosis,Age of patient is important,Accurate history and complete exam essential,FNAB invaluable diagnostic tool,Possibility for malignancy in any age group,Close follow-up and aggressive approach is best for favorable outcomes,69,References,Armstrong W, Giglio M. Is this lump in the neck anything to worry about? September 1998. Postgraduate Medicine.,Schwetschenau E, Kelley D. The Adult Neck Mass. Sep 2002. American Family Physician.,70,