neck mass evaluation & management - ksu
TRANSCRIPT
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Neck massEvaluation & Management MOHAMMED ALESSA MBBS,FRCSC
ASSISTANT PROFESSOR
CONSULTANT
OTOLARYNGOLOGY , HEAD & NECK SURGICAL ONCOLOGY
KSU , MEDICAL CITY & KKUH
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ObjectivesObtain map overview in neck surgical anatomy .
Differential diagnosis of adult neck mass .
Differential diagnosis of pediatric neck mass .
Work up of a patient with neck mass
Management
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Neck Surgical Anatomy
Anterior triangle
-Common carotid artery ( its branches),
-Cranial nerves ( VII,X,XI,XII) , Symphatic chain,
-Lymph nodes,
-Organs :
Pharynx , Esophagus Larynx , Trachea Thyroid gland Salivary glands
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Neck Surgical Anatomy
Anterior triangle
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Neck surgical anatomy
Posterior triangle:
- Subclavian A&V , branches,
- Nerves : CN (XI), phrenic N , Brachial plexus,
- Lymph nodes
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Differential DX Neck mass
Neoplastic Inflammatory/ Congenital
Infectious Carcinoma (CA)
- Squamous ( SCC) Granulomatous dis Thyroglossal duct cyst
- Adeno Branchial cyst
Lymphoma Bacterial Ranula
Metastatic CA viral vascular malformation
- oral cavity , pharynx Teratoma
-Thyroid Layngocele
-Salivary gland
- osseous lesion ( amelobalstoma)
- Infracalvicaular
Adult Pediatric
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Adult neck masswork up
Obtain a through History might narrow DDX spectrum etiologies ,
Neck , ear , nasal , oral & pharyngeal examination will provide site localization ,
Get a DDx list ,
Order Laboratory investigations based on DDx priority list,
Order Radiological investigations based on DDx priority list .
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Neck masswork up , History
Congenital Infectious Neoplastic
Pain Rare Common Rare
Duration Long Short Long
Constitutionalsymptoms
None Fever , Weight loss , Loss of appetite
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Neck masswork up , physical examination
Congenital Infectious Neoplastic
Consistency Soft , firm Soft , firm Hard
Mobility Common common Rare
Tenderness Rare Very common Rare
Number Solitary Solitary vs multiple
Multiple
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Radiology & laboratories •U/S,
•Computed tomography ( CT scan with contrast ),
•Magnetic resonance imaging ( MRI ) ,
•Positron emission tomography ( PET),
•Fine needle aspiration cytology ( FNA),
•Open biopsy ( remember indications).
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RadiologyUS
Advantages :
Aviliability & affordability ,
Safety ,
Non invasive
Consistency
Disadvantages :
Operator dependent ,
Anatomical assessment,
Soft tissue & osseous details I.e. trachea , esophagus
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Radiology CT Scan
Advantages :
Static ,
Anatomical assessment ,
Osseous assessment,
Soft tissue details ( contrast).
Disadvantages :
Affordability,
Safety pregnancy
childhood
contrast allergy & anaphylaxis
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Radiology MRI
Advantages :
Safety ( pregnancy )
Non invasive ,
Soft tissue assessment,
Skull base ( perineural invasion) .
Disadvantages :
Magnetic
Affordability
Age limitation , ( sedation)
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Radiology PET
Nuclear medicine
( functional imaging)
FDG uptake,
Integrated with anatomical studies.
Indications :
Staging & surveillance ( malignancy),
Role in unknown primary
Head & Neck neoplasm .
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FNA
• Minimum : 3-4 passes,
• Skillful cytotechnican &
cytopathologist on site .
• Indication US guided FNA:
Non diagnostic conventional FNA
Non palpable masses
> 50% cystic content .
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Open neck biopsy Avoid it in HNSCC
Indication :
•Non diagnostic FNA ( At least 2 attemps) without evidence of primary lesions ( clinical, radiological , EUA)
•Suspicious of certain Dx
Hematological pathologies I.e. lymphoma
Granulomatous diseases
Inflammatory disease
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Differential DX Neck mass
Neoplastic Inflammatory/ Congenital
Infectious Carcinoma (CA)
- Squamous ( SCC) Granulomatous dis Thyroglossal duct cyst
- Adeno Branchial cyst
Lymphoma Bacterial Ranula
Metastatic CA viral vascular malformation
- oral cavity , pharynx Teratoma
-Thyroid Layngocele
-Salivary gland
- Infracalvicaular
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Neck masssalivary glands
•Parotid gland
•Submandibuar gland
•Sublingual gland
•Minor salivary gland ( oropharynx , nasal cavity )
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Salivary gland : Sialolithiasis
•Submandibular gland
( most common)
•Recurrent painful swelling
•Aggravated by eating
Dx:
CT scan neck
Management:
Treat underlying infection
Sialoendoscopy & lithotripsy &
stone removal
Submandibular gland excision
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Salivary gland: Neoplasm
•80% parotid gland
•80% benign
•80% polymorphic adenoma
• Slowly painless enlarging mass
Dx:
CT neck with contrast
MRI with contrast
FNAC
Management:
Excision Superficial parotidectomy Submandibular gland excision
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Salivary gland: malignant neoplasm
•Rapidly enlarging mass
•Pain
•Fixation into adjacent structures
•Lymphadenopathy
•Facial nerve paralysis
Dx:
CT ,MRI neck with contrast
FNA
True cut biopsy
Management
Total parotidectomy
+/- facial nerve resection
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Osseous neoplasm Ameloblastoma
• benign neoplasm of uncertain origin,
• locally invasive
• Age : 3-4 decades
• Mandible ( most common)
• Painless , slowly growing
( facial asymmetry)
Dx:
Panorex
MRI mandibule
Incisional biopsy
Management:
Wide local excision with 1 cm margin
Immediate reconstruction)
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Case scenario 55 year old male .
Neck mass .
How would it be approached ?
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Case scenario Painless slowly enlarging over 2-3 month with dysphagia & 10 pound/weight loss .
No other lymphadenopathy
Normal Cranial nerve .
Level II lymph node 3-4 cm , hard
What further examination mandated ?
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Case scenario
Flexible nasopharyngoscopy.
CT neck with contrast
FNA : Squamous cell CA (SCC)
What is next point in investigations ?
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case scenariounknown primary Head & Neck SCC (HNSCC)
Quadrascopy◦ Esophagoscopy
◦ Laryngoscopy
◦ Pharyngoscopy ( EAU Nasopharynx & ipsilateral tonsillectomy)
◦ Bronchoscopy
PET/CT scan helpful in these cases .
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HNSCC
known Unknown
SCC Primary
Treatment : Based on primary sub site:
I.e. Oropharynx < Radiation therapy
(XRT) to primary and neck >
Radical neck dissection +/- XRTOr
XRT + Chemotherapy
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Case scenario •2 attempts FNA : Nondiagnostic .
•What is your next line in management ?
•Open biopsy • Granuloma TB , Sarcoidosis
• Inflammatory process or abscess G stain , culture
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Congenital Neck masses
Age : Neoante
Prenatal : polyhydrominous .
Antenatal : airway obstruction
Dx : Teratoma
Management :
Multidisciplinary team approach .
EXIT procedure
Secure airway ( intubation & trachestomy)
Surgical resection
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Congenital Neck masses
Age : child or adulthood
Midline neck mass , sinus ( URTI)
Dx:
U/S neck : Identify Thyroid gland in its
anatomical location .
Dx: Thyrglossal duct cyst
Management :
Sistrunk procedure
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Branchial anomalies
• Age : child, adulthood
• Lateral neck mass , sinus ( URTI)
• Dx:
U/S , CT scan confirm finding
FNA ( adult) , R/O metastatic SCC
• Management : Excision ( stepladder )
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plunging ranula
• Mucocele ( floor of mouth)
• Age : children more common
• Midline neck mass ( submental area)
• Floor of mouth mass ( compressible)
Dx:
CT ,MRI neck
Management :
Excision of mucocele & sublingual gland ( trans oral)
Marsupizilation
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Vascular malformationHemangioma • Age : Infant ( 6 month )
• Neck mass , skin discoloration
• Dx:
MRI Neck with contrast .
• Management :
Reassurance ( resolve spontaneously )
Medical Rx systemic steroid , propranolol ) , laser therapy ,surgical resection
Aerodiagsteive symptomatology Vision loss Cosmesis
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lymphangioma
• Age : newborn
• Lateral or midline neck mass
• Dx:
MRI neck with contrast
( low flow)
• Management :
Sclerotherapy
Surgical resection
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Neck mass/infectiousLudwig's angina
•Age : adult
•Recent odontogenic infection,
•Rapidly progressing submental
& floor of mouth swelling
•Acute airway obstruction
Dx:
Clinical exam
CT scan neck ( contrast)
Management :
Secure airway , tracheotomy
Abscess Incision & drainage
dentistry consult
Systemic Abx
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Infectiouscat scratch disease • Age : Childhood
• HX of Cat exposure
• Cutaneous lesion ,
• Cervical lymphadenopathy
tender painless
• Fistula
Dx :
Cat scratch Ag
C/S : G –ve intracellular bacillus
( Warthin Starry stain)
Pathology : granuloma &
micro abscess
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Infectiouscat scratch disease
Management :
Reassurance
Aspiration
Avoid Incision /drainage
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infectiousAtypical mycobacterium • Age : childhood , unlikely adult.
• HX of foreign travel , immunocompromised.
• Corneal ulceration
• Unilateral cervical adenopathy
( skin adherent)
Dx :
AFB stain ( 2-4 weeks)
PCR
PPD ( often not helpful)
Pathology : granuloma
Management :
Complete excision ( Neck dissection)
Avoid incision & drainage
Antimicrobial resistance .
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Neck mass/infectious
atypical mycobacteriumM.AviumM.scrofulaceumM.Intracelluare
Typical mycobacteriumM.Tuberculosis
Age Children Elderly
Patient characteristics Foreign travel Immunocompromised
HIV ( immunocompromised) Poor socioeconomics Immigrant
Pulmonary & systemic involvement
Rare Common
Cervical lymphadenopathy
Unilateral Anterior triangle Tender
Bilateral Ant & posterior triangle Non tender
Management Excision ( Neck dissection) Antimicrobial
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Neck mass Kawasaki syndrome
Age : childhood
Fever , rash , conjunctivitis ,
dry red lip & Strawberry tongue
Cervical lymphadenopathy
Pathophysiology : vasculitis
Complication : Acute MI
Dx
CBC : Thrombocytosis
ESR :
Echocardiography :
coronary aneurysm.
Managment :
Ɣ globulin
Aspirin
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Lipoma
• Age : adult
• Painless , soft neck mass
Dx:
CT scan
( clinical exam is adequate)
Management :
Excision
Observation
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Conclusion In Dental /OMFS practice neck mass usually from infection etiology .
Most of time due to odontogenic source .
Trial of systemic Antibiotics for 2 weeks .
Referral to Head & Neck surgeon
If no response to medical therapy.
Concern about airway obstruction.