neck mass - alexu.edu.eg

Hatem Alwagih Neck Mass

Neck Mass Hatem Alwagih

Associate Professor of Surgery

Department of Surgery

Faculty of Medicine

University of Alexandria

[email protected]

Evaluation which leads to the proper treatment and the best outcome

Learning Objectives

1- Describe a systematic method for evaluating patients with neck masses

2- Suggest the appropriate diagnostic studies

3- Discuss differential diagnosis of neck masses

4- Describe the outlines of surgical treatment of neck masses

Classification Neck masses can be originated from: Skin, Endocrine organs, Upper

aerodigestive Tract, Vessels, or Lymph Nodes

They are classified into:

• Congenital

• Acquired

o Inflammatory

o Benign Neoplasm

o Malignant Neoplasm

Evaluation which leads to the proper treatment and the

best outcome follows the following 4 steps: I Appropriate initial assessment

II Role and technique of FNAB

III Appropriate use and interpretation of imaging

IV Management: Importance of specialized multidisciplinary care if malignancy

is suspected

mailto:[email protected]


I Appropriate Initial Assessment

The correct diagnosis of a lump in the neck can often be made with a careful

history and examination. The clinical signs of size, site, shape, consistency,

fixation to skin or deep structures, pulsation, compressibility, transillumination

or the presence of a bruit still remain as important as ever

• Age

• Location

• Risk Factors

• Symptoms

• Head & Neck Exam

Age

Young Adult

• Congenital

• Inflammatory

• Malignant

Age

Adult ( >40)

• Malignant

• Congenital

• Inflammatory

Pediatric

• Inflammatory

• Congenital

• Malignant


Age & Location: The Adult with a Lateral Neck Mass

Location

Angle of Mandible

• Parotid

Central Compartment

• Thyroid

Lateral Neck

• Lymph Node

Age & Location: The Adult with a Lateral Neck Mass

80% Neoplastic

20% Inflammatoryor Congenital

20% Benign

80% Malignant

20% Primary

80% Metastatic

Neck Mass

“Rule of 80’s”


Risk Factors

•Sexual Behavior

HPV & HN

• Male predominance Cancer

• Younger patients

• Fewer traditional risk factors

• Sexual behavior as risk factor multiple sexual partners (>6) higher rates of

oro-genital contact with multiple partners

•Sun Exposure

Symptoms of Head and Neck Primary

● Otalgia, unilateral ● Hemoptysis

● Nasal obstruction (snoring) ● Unilateral hearing loss

● Dysphagia ● Epistaxis

● Hoarseness

Symptoms of Lymphoma

● Fever

● Night Sweats

● Weight Loss

Physical Exam What do we need to document?

• Location of the mass in the neck

• Presence/absence of a primary in the head and neck

• Presence/absence of generalized lymphadenopathy


Physical Exam

Physical Exam


- Triangles

- Levels

III

III

IVV

Physical Exam


- Triangles

- Levels

III

III

IVV

Physical Exam

• Lymph nodes

- oral cavity

- skin

I I


Physical Exam

• Lymph nodes

- oropharynx

II

Physical Exam

• Lymph nodes

- larynx

- hypopharynx

- thyroid

III


Physical Exam

• Lymph nodes

-Thyroid

-Below Clavicle

IV

Physical Exam

• Lymph nodes

- nasopharynx

V

Physical Exam

• Presence/absence of a primary in the head and

neck - oral cacvity and oropharynx

Mashberg. Cancer 1973,32:1436-1445

Distribution of

Early Oral Cancer


Physical Exam

• Presence/absence of a primary in the head and

neck - oropharynx and larynx

Palpation Base of Tongue

Fiberoptic Nasendoscopy

II Role and Technique of FNAB

• Needle size: 25 gauge

• 12-15 Passes should be performed

•Immediate assessment of adequacy by the Pathologist is the rule

FNAB Immunohistochemistry

SCC

Cytokeratin

Positive

Lymphoma

CD45/CD30

Positive

Poorly Differentiated

Malignancy


Fine Needle

Aspirartion Biopsy

Diagnosis of Lymphadenopathy

• Sensitivity 85-97%

• Specificity 98-100%

• Nondiagnostic 8-16%

• Open Biopsy 22-30%

Role of Open Lymph Node Biopsy

Excisional/Incisional Biopsy may be necessary:

• Sub classification of lymphoma

• Facilitate diagnosis of poorly differentiated carcinoma

• Persistently nondiagnostic FNAB


III Appropriate use and Interpretation of Imaging

CT

MRI Adults with a lateral neck mass

Assess possible primary

USChildren

Central compartment, all ages

PETMultidisciplinary planning for

select malignant tumours

IV Management: Importance of specialized multidisciplinary care if malignancy is suspected


Non-malignant neck lumps

1. Cystic hygroma (Lymphangiomas)

• It is a congenital lesion usually present within

the first year of life. (Posterior Triangle)

• Usually remain unchanged into adulthood

• Soft, cystic, multilocular, partially

compressible and brilliantly transilluminant

and may present with pressure effects

• CT or MRI may help define the extent of the

neoplasm

• Treatment of Lymphangiomas includes injection with picibanil or

excision for easily accessible lesions or those affecting vital functions

2 Branchial cleft cysts

• Remnant of branchial cleft (2nd)

• Most commonly occur in the second or third

decades

• Pain +/- (severe throbbing pain)

• Usually presents as a smooth, fluctuant non tender

(tender), non transilluminant mass mobile forwards

and downwards, underlying the anterior border of

the sternomastoid muscle.

• Branchial fistula or sinus

• Primary treatment is with control of infection by antibiotics, followed by

surgical excision.


3. Thyroglossal duct cyst

• This is a common congenital midline neck mass

• Sometimes at the lateral edge

• Pain and tenderness +/-

• Can be moved transversally but

• Elevates on protrusion of the tongue.

Treatment is with initial control of infection with

antibiotics, followed by surgical excision including the

mid-portion of the body of the hyoid bone (Sistrunk’s

procedure). Occasionally, these lesions become

infected and resolve, or persist following drainage as a

thyroglossal fistula.

4. Lipoma

• Lipomas are the most common benign soft tissue neoplasm in the neck.

They are poorly defined, soft masses usually after the fourth decade.

• They are usually asymptomatic, soft.

• FNAC or MRI Scan can confirm the diagnosis.

• Surgery is indicated when the lump is increasing in size, cosmesis, or

when there is doubt about the accuracy of diagnosis.

5. Sebaceous cysts

• These are common masses occurring often in older people but can occur

at any age.

• They are slow growing, but sometimes fluctuant and painful when

infected.

• Diagnosis is made clinically; the skin overlying the mass is adherent and

a punctum is often identified.

• Excisional biopsy confirms the diagnosis.


6. Cervical lymphadenopathy

• Acute lymphadenitis

• tender swelling

• Antibiotic trial, less acute inflammatory nodes generally regress in size

over 2–6 weeks.

• If the lesion does not respond, biopsy is warranted

7. TB cervical lymphadenitis

• Upper and middle deep cervical LN

• Onset: gradually

• Pain: +/-

• Systemic symptoms unusual in young

• Abscess (painful, increase size, and skin discoloration )

• Mass: indistinct, firm, matted, fluctuate!

• Temperature!(Cold abscess)

• Treatment with anti TB (6-9 months) Rifampicin Ethambutol INH

Pyrazinamide


8. Carotid body tumour

• Rare tumour of chemo receptors (40-60 years).

• Slow-growing painless some time pulsating lump

may be bilateral.

• Side to side movement

• Symptoms of transient cerebral ischemia!

• Potato tumors (hard, non tender)

• Palpation may induce vasovagal attack

• Biopsy is contraindicated MRI

• Angiography is the investigation of choice.

• Surgical removal is based on patient factors and

presenting symptoms.

9. Pharyngeal pouch

• Diverticulum of the pharynx through the gap

between the horizontal fibers of the

cricopharyngeus muscle below and the

lowermost oblique fibers of the inferior

constrictor muscle above.

• History of froth and acid taste

• Halitosis regurgitation of food. There is no

bile or to it.

• Pressure on the swelling causes gurgling

sounds and regurgitation

• Treatment: cricopharyngeal myotomy


10. Ludwig's angina

• Rare but serious connective tissue infection of the floor of the mouth

• Mostly due to dental infections

• Sings of inflammation present

• Treatment: drainage of pus + antibiotic to cover aerobes with anaerobes

11 Thyroid masses

• Thyroid neoplasms are a common cause of anterior compartment neck

masses in all age groups, with a female predominance, and are mostly

benign.

• Fine needle aspiration of thyroid masses has become the standard of care

and ultrasound may show whether the mass cystic.

• Unsatisfactory aspirates should be repeated, and negative aspirates

should be followed up with a repeat FNAC and examination in 3 months’

time.

Characteristics of malignant neck lumps

1. Lymphomas

• Painless lump, non tender smooth and discrete

• Slow growing

• Patient Presented with malaise, wt. loss, pallor.

• Fever, rigor and Hepatosplenomegaly

• Mediastinal mass (SVC syndrome)

• Abdomen pressure on IVC may cause bi lateral leg oedma

• Other lymph nodes in the axilla, groin and abdomen should examined.

• Treatment: according to stage (radiosensitive)


2. Metastatic Lymph Nodes

• Upper cervical lymph nodes (upper aerodigestive tract).

• Accessory chain of nodes in the posterior triangle (Nasopharyngeal

malignancies).

• (Occult primary) most common sites are tonsil, base of tongue,

nasopharynx and Piriform sinus.

• Virchow's LN (Toisier ’s sign) abdominal and thoracic malignancies

• Painless, non tender, and hard masses

• Work up: Search for primary and deal with it

neck mass - alexu.edu.eg

Documents