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Evaluation and Management of the Patient with a Neck Mass Bastaninejad, Shahin, MD, ORL and HNS Specialist.

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Presentation on theme: "Evaluation and Management of the Patient with a Neck Mass Bastaninejad, Shahin, MD, ORL and HNS Specialist."— Presentation transcript:

1 Evaluation and Management of the Patient with a Neck Mass Bastaninejad, Shahin, MD, ORL and HNS Specialist

2 Anatomy

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4 History and P.Exam.

5 Historical Points Age: –Up to 15yrs (pediatrics)  more than 90% benign –16 to 40 (young adult) –More than 40yrs (older adults)  80% neoplasm  80% of them malignant (secondary>>primary) Time course immunodeficiency

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7 Prior trauma Travel, Irradiation, Surgery Associated symptoms  fever, dysphagia, weight loss, otalgia, hearing loss, respiratory difficulties Perform a FULL head and neck examination

8 Diagnostic imaging

9 Modality Basic Indications Ultrasound Good for pediatric neck masses, thyroid masses. Differentiates cystic versus solid. Computed tomography Workhorse imaging modality for adult neck masses. Provides three-dimensional relationships, excellent detail of mucosal disease and involvement of adjacent bone. Magnetic resonance imaging Superior soft tissue delineation. Good for lesions of the salivary glands and tongue (where dental amalgam may obscure the view on a CT). Modality of choice for determining nerve enhancement. Consider for thyroid imaging in cases necessitating radioiodine. Radionuclide scanning Useful for midline lesions in children—differentiates functioning from nonfunctioning tissue. Positron emission tomography Useful for staging of head and neck malignancies. Can be used in cases of unknown primary malignant neck masses or treated neck disease. Angiography/magnetic resonance angiography/computed tomography angiography Useful for lesions encasing the carotid and vascular lesions. Conventional angiography should be considered for preoperative assessment in cases of potential carotid artery sacrifice or where embolization is required. Plain radiograph Generally should not be considered in the workup of a neck mass. Table 116-1 -- Imaging of Neck Masses

10 Initial w/u of the unknown neck mass

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12 FNA Re-FNA core needle Bx excisional BxFNA  if unsuccessful or less informative  consider Re-FNA  failure again  consider core needle Bx  Failure again  excisional Bx and if it was SCC, consider simultaneous neck dissection procedure

13 Differentials for Unknown neck mass

14 Inflammatory causes The most common neck masses LAP: –typically subside without tx –sometimes it become necrotic and an abscess forms (Staph./Strep.) Granulomatous disease: TB, atypical mycobac., actinomycosis, cat scratch, syphilis. –FNA better than excision (because of the risk of non- healing wound)

15 Sialadenitis and Sialolithiasis –Abx –Hydration –Warm compresses –Massage –sialogogues

16 Congenital neck masses TGDCTGDC second in frequency –In pediatric they are second in frequency only to LAP –Elevates in the neck with tongue protrusion –If it becomes infected: Avoid I&D  Choice is Aspiration and Abx. –Main procedure is Sistrunk procedure

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18 Branchial cleft anomaliesBranchial cleft anomalies –Anomalies: cyst, sinus, fistula –30% of the pediatric neck masses 2 nd Arch anomaly: –95% of them  2 nd Arch anomaly: Manifest as a lateral neck swelling associated with an URI Like TGDC, avoid I&D Tract pathway is lateral to the ICA, and enters to the pharynx at the tonsillar fossa Its swelling bulk or draining tract is anterior to the SCM muscle

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21 1 st Branchial Cleft anomaly –1% of branchial cleft anomalies –Associated with VII nerve –Fistula, cyst & sinuses located between EAC and the angle of the mandible Type 1: EAC duplication, contain ectodermal elements, it’s lateral to the VII nerve Type 2: Contain ectodermal and mesodermal elements (meso  cartilage), it’s deep to the VII nerve

22 3 rd and 4 th BCA3 rd and 4 th BCA –Extremly uncommon –Swelling or sinus tract in the lower neck, anterior to the SCM muscle –3 rd : –3 rd : Deep to the CA, pierce thyrohyoid membrane and enters the pharynx at pyriform sinus –4 th : –4 th : Deep to the CA, close to the thyroid gland, enters pyriform sinus or cervical esophagus

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24 Dermoid cyst: contains ectodermal and endodermal elements Teratomas: –all three germ layers –Less than 2% of all body teratomas are in H&N, most commonly: neck and nasopharynx Lymphangioma  most common in posterior triangle

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26 Hemangioma: –Commonly occure in H&N and it’s present at birth –Phases: Rapid expansion (6-12mo) Stable phase; no/minimal change occures Involution; usually begins by 24mo –50% complete in 5yr age –Nearly all tumors regress by 10-12yr s age

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28 Neck Neoplasms

29 Primary neoplasm of the neck Lymphoma:Lymphoma: –Most common H&N malignancy in Ped. –2 nd most common overall H&N malignancy second only to SCC (  SCC is the most common H&N cancer) –Non Hodgkin (*5) > Hodgkin –90% B cell

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31 Thyroid neoplasm: –Most common neoplastic anterior neck masses in all age groups –More than 90% of all thyroid nodules are benign Malignancy probability is greater in very young children, very old age population and males Salivary gland neoplasm –1% of all H&N masses –MEC is the most common salivary malignancy

32 Salivary gland neoplasmSalivary gland neoplasm, Continue: %80 is from parotid gland  %80 benign  majority: benign mixed tumor %15 SMG  %50 malignant %5 S.Lingual & minor glands  More than %75 malignant –Neurogenic Neoplasm –Neurogenic Neoplasm: Schwanoma –Is the most common neurogenic tumor –Parapharyngeal space is a common location Neurofibroma –There is a %2-6 risk of malignant degeneration (malignant nerve sheet tumor)

33 Neurogenic Neoplasm,Neurogenic Neoplasm, Continue: –Neuroblastoma, ganglioneuroblastoma,... –Neuroma  it is a complication of truma, mainly greater auricular nerve ParagangliomaParaganglioma  neuroectodermal origin –Carotid body (angiography  Lyre’s sign) –Jugulotympanic region  usually not a neck mass –Vagus nerve

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35 Lipoma

36 Work up for Unknown Primary, SCC of the Neck

37 1. complete physical examination (inspection and palpation) of all head and neck subsites Oral cavity Oropharynx Thyroid Salivary glands Face/scalp/neck skin 2. Fiberoptic endoscopy examination Nasal cavity Nasopharynx Oropharynx Hypopharynx Larynx 3. Fine-needle aspiration Table 116-2 -- Steps in the Workup of an Unknown Primary Squamous Cell Carcinoma of the Neck

38 4. Primary imaging Head and neck (computed tomography or magnetic resonance imaging) Chest (radiograph or computed tomography) 5. Secondary imaging Positron emission tomography 6. Panendoscopy/ Directed mucosal site sampling Include laryngoscopy, bronchoscopy, esophagoscopy, and ipsilateral tonsillectomy. Pay close attention to the tongue base and hypopharynx.

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