Head and neck masses - evaluation and management

Question 1

Anatomical considerations

Answer 1

Prominent landmarks
Triangles of the neck
Carotid bulb
Lymphatic levels

Question 2

Common neck masses

Answer 2

Neoplastic
Congenital/ developmental
Inflammatory

Question 3

General considerations: pt age

Answer 3

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

Question 4

General considerations: location

Answer 4

Congenital masses: consistent in location

Metastatic masses: key to primary lesions

Question 5

History

Answer 5

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

Question 6

Empirical antibiotics

Answer 6

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

Question 7

Special investigation

Answer 7

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

Question 8

Fine needle aspiration FNA

Answer 8

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 ?)

Question 9

Fine needle aspiration biopsy

Answer 9

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

Question 10

Ultrasonography

Answer 10

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

Question 11

Computed tomography

Answer 11

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

Question 12

Magnetic resonance imagine

Answer 12

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

Question 13

Magnetic resonance imagine

Answer 13

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

Question 14

Radionucleotide scanning

Answer 14

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

Question 15

Nodal mass workup in the adult

Answer 15

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

Question 16

Panendoscopy

Answer 16

FNA positive with no primary on repeat exam

FNA equivocal/negative in high risk patient

Question 17

Directed biopsy

Answer 17

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

Question 18

Open excisional biopsy

Answer 18

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

Question 19

Primary tumours

Answer 19

Thyroid mass
Lymphoma
Salivary tumors
Lipoma
Carotid body and glomus tumors
Neurogenic tumors

Question 20

Thyroid masses

Answer 20

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

Question 21

Thyroid masses - lymph node metastasis

Answer 21

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

Question 22

Thyroid masses - FNAB has replaced USG and radionucleotide scanning

Answer 22

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

Question 23

Lymphoma

Answer 23

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

Question 24

Salivary gland tumours

Answer 24

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

Question 25

Carotid body tumour

Answer 25

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

Question 26

Lipoma

Answer 26

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

Question 27

Neurogenic tumours

Answer 27

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

Question 28

Schwannoma

Answer 28

``` 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) ```

Question 29

Congenital and developmental mass

Answer 29

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

Question 30

Epidermal and sebaceous cysts

Answer 30

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

Question 31

Branchial cleft cysts - cause - presentation - epidemiology - treatment

Answer 31

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)

Question 32

Thyroglossal duct cyst

Answer 32

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

Question 33

Vascular tumours

Answer 33

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)

Question 34

Inflammatory disorders

Answer 34

Lymphadenitis | Granulomatous lymphadenitis

Question 35

Lymphadenitis

Answer 35

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

Question 36

Lymphadenopathy

Answer 36

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

Question 37

Granulomatous lymphadenitis

Answer 37

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

Question 38

Granulomatous lymphadenitis bacteria

Answer 38

``` 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 ```