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ENT + Opthalmology > Head and neck masses - evaluation and management > Flashcards

Head and neck masses - evaluation and management Flashcards

1
Q

Anatomical considerations

A

Prominent landmarks
Triangles of the neck
Carotid bulb
Lymphatic levels

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2
Q

Common neck masses

A

Neoplastic
Congenital/ developmental
Inflammatory

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3
Q

General considerations: pt age

A 
Paediatric (0-15 years): 90% benign
Young adult (16-40 yrs): similar to pediatric
Late adult (>40 years): "rule of 80s"
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4
Q

General considerations: location

A

Congenital masses: consistent in location

Metastatic masses: key to primary lesions

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5
Q

History

A

Developmental time course
Associated symptoms (dysphagia, otalgia, voice)
Personal habits (tobacco, alcohol)
Previous irradiation or surgery

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6
Q

Empirical antibiotics

A

Inflammatory mass suspected
Two week trial of antibiotics
Follow-up for further investigation

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7
Q

Special investigation

A 
Fine needle aspiration cytology (FNAC)
Needle Core Biopsy 
-gives best result
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Ultrasonography 
Radionucleotide scanning
PET scan
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8
Q

Fine needle aspiration FNA

A 
Standard of diagnosis
Indications
-any neck mass that is not an obvious abscess
-persistence after a 2 week course of antibiotics
Small gauge needle 
-reduces bleeding
-seeding of tumor – not a concern 
No contraindications (vascular ?)
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9
Q

Fine needle aspiration biopsy

A 
Proper collection required 
One-stop neck lump clinic
Under USS guidance 
Skilled cytopathologist/ Radiologist essential
On-site review best
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10
Q

Ultrasonography

A

Solid versus cystic masses
Congenital cysts from solid nodes/tumors
Noninvasive (paediatric)

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11
Q

Computed tomography

A

Distinguish cystic from solid
Extent of lesion
Vascularity (with contrast)
PET-CT Detection of unknown primary (metastatic)
Pathologic node (lucent, >1.5cm, loss of shape)
Avoid contrast in thyroid lesions

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12
Q

Magnetic resonance imagine

A

Similar information as CT
Better for upper neck and skull base
Vascular delineation with infusion

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13
Q

Magnetic resonance imagine

A

Similar information as CT
Better for upper neck and skull base
Vascular delineation with infusion

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14
Q

Radionucleotide scanning

A

thyroid and parathyroid masses
Location – glandular versus extra-glandular
Functional information
FNAC now preferred for thyroid nodules
-solitary nodules
-multinodular goiter with new increasing nodule
-Hashimoto’s with new nodule

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15
Q

Nodal mass workup in the adult

A

Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise
Asymptomatic cervical mass – 12% of cancer
~ 90% of these are SCC
Ipsilateral otalgia with normal otoscopy – direct attention to tonsil, tongue base, supraglottis and hypopharynx
Unilateral serous otitis – direct examination of nasopharynx
Panendoscopy, directed biopsy, synchronous primaries (10 to 20%), open excisional biopsy

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16
Q

Panendoscopy

A

FNA positive with no primary on repeat exam

FNA equivocal/negative in high risk patient

17
Q

Directed biopsy

A

All suspicious mucosal lesions
Areas of concern on CT/MRI
None observed – nasopharynx, tonsil (ipsilateral tonsillectomy for jugulodigastric nodes), base of tongue and piriforms

18
Q

Open excisional biopsy

A

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

19
Q

Primary tumours

A 
Thyroid mass
Lymphoma
Salivary tumors
Lipoma
Carotid body and glomus tumors
Neurogenic tumors
20
Q

Thyroid masses

A 
Leading cause of anterior neck masses
Children
-most common neoplastic condition
-male predominance
-higher incidence of malignancy
Adults
-female predominance
-mostly benign
21
Q

Thyroid masses - lymph node metastasis

A

Initial symptom in 15% of papillary carcinomas
40% with malignant nodules
Histologically (microscopic) in >90%

22
Q

Thyroid masses - FNAB has replaced USG and radionucleotide scanning

A

Decreases # of patients with surgery
Increased # of malignant tumors found at surgery
Doubled the # of cases followed up
Unsatisfactory aspirate – repeat in 1 month

23
Q

Lymphoma

A

More common in children and young adults
Up to 80% of children with Hodgkin’s have a neck mass
Signs and symptoms
-lateral neck mass only (discrete, rubbery, nontender)
-fever
-hepatosplenomegaly
-diffuse adenopathy
open biopsy
Full workup – CT scans of chest, abdomen, head and neck; bone marrow biopsy

24
Q

Salivary gland tumours

A

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
-FNAC: 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

25
Q

Carotid body tumour

A

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

26
Q

Lipoma

A

Soft, ill-defined mass
Usually >35 years of age
Asymptomatic
Clinical diagnosis – confirmed by excision

27
Q

Neurogenic tumours

A

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

28
Q

Schwannoma

A 
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)
-Horner’s syndrome (sympathetic chain)
29
Q

Congenital and developmental mass

A

Epidermal and sebaceous cysts
Branchial cleft cysts
Thyroglossal duct cyst
Vascular tumors

30
Q

Epidermal and sebaceous cysts

A

Most common congenital/developmental mass
Older age groups
Clinical diagnosis
-elevation and movement of overlying skin
-skin dimple or pore
Excisional biopsy confirms

31
Q

Branchial cleft cysts

  • cause
  • presentation
  • epidemiology
  • treatment
A

Branchial cleft anomalies
2nd cleft most common (95%) – tract medial to cnXII between internal and external carotids
1st cleft less common – close association with facial nerve possible
3rd and 4th clefts rarely reported
Present in older children or young adults often following URI
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 (1st cleft)

32
Q

Thyroglossal duct cyst

A

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

33
Q

Vascular tumours

A

Lymphangiomas and hemangiomas
Usually within 1st year of life
Hemangiomas often resolve spontaneously, while lymphangiomas remain unchanged
CT/MRI may help define extent of disease
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)

34
Q

Inflammatory disorders

A

Lymphadenitis

Granulomatous lymphadenitis

35
Q

Lymphadenitis

A

Very common, especially within 1st 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

36
Q

Lymphadenopathy

A

Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease

37
Q

Granulomatous lymphadenitis

A

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

38
Q

Granulomatous lymphadenitis bacteria

A 
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 
Atypical M. tuberculosis
-pediatric age groups
-anterior triangle nodes
-brawny skin, induration and pain
-usually responds to complete surgical excision or curettage
Cat-scratch fever (Bartonella)
-pediatric group
-preauricular and submandibular nodes
-spontaneous resolution with or without antibiotics

ENT + Opthalmology (4 decks)

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