Neck Mass Flashcards
Differential diagnosis of neck mass
Based on location of mass, type of disease, age
Location: Anterior, Midline, Posterior
Type of disease: congenital/developmental, inflammatory, neoplasm
Age:
0-15 yrs (congenital, inflammatory, malignant, benign)
15-40 yrs (inflammatory, congenital, benign, malignant)
>40 yrs (inflammatory, malignant, benign, congenital)
How do you examine the neck
Inspection: - Look for swelling, its location, size, overlying skin changes, regularity. - If mass in midline, ask to swallow and protrude the tongue to see if the mass rises up (thyroglossal duct cyst, thyroid mass) Palpation: - tenderness - consistency - margin - regularity - mobility or fixation - temperature - pulsation Auscultation: - bruit (CBT, CAA)
Investigations of neck masses
Plain films (OPG, Lat neck, Neck PA) Ultrasound CT MRI Biopsy (Fine needle, core biopsy, incisional)
What are components of history to ask in neck mass
Chief complaint with associated symptoms Duration of swelling Dysphagia Dysphonia Prior hx of surgery or radiation
Thyroglossal duct cyst
- at junction between oral & oropharpharyngeal tongue
- commonly inferior to hyoid bone & move with hyoid bone ( ie. Elevated with tongue protrusion/up & down with swallowing
- can get infected or harbor thyroid malignancy
- *before removal test for functional thyroid— don’t want to remove all function thyroid
Branchial cleft cyst
- 1st branchial cleft (1%): duplication of EAC or within parotid, deep to facial nerve
- 2nd branchial cleft (95%)- anterior to SCM with tract between ICA & ECA superficial to hypoglossal & glossopharyngeal nerves ending in tossillar fossa
- 3rd & 4th (extremely rare)
Examples of Inflammatory/infective lesions
Infection
- viral (PMV mumps, EBV, CMV, HSV -infectious mononucleosis)
- bacterial (tb, syphillis, cat scratch dz)
- fungal/parasitic (toxoplasmosis)
Inflammatory
- autoimmune (sarcoidosis)
Examples of benign neoplasms
- paragangliomas
- carotid paragangliomas
- vagal paragangliomas
- peripheral nerve neoplasms
- parapharyngeal space tumors
- thyroid nodules
- lipomas
Presentation of CBT
Fontaine sign (mobility laterally, but not cranial/caudally) Other symptoms: bruit, compressive symptoms & nerve deficits, carotid sinus syndrome syncope 1-3% are functional- headache & flushing perspiration
What are types of peripheral nerve neoplasms?
Schwannomas
Neurofibromas
nerve sheath tumors, MRI used for dx
Classical finding of Schwannoma
Appear bright white on T2 MRI, encapsulated
Types of neck dissection
- radical: levels I-V, SCM, IJV, CNXI
- MRND: levels I-V, preservation of SCM, IJV, SAN
- selective: preserve 1+ nodal levels
- extended: remove additional nodal level or nonlymph structure
- planned: 6-8wks post radiation
- salvage: performed for recurrence
Selective neck dissection
Supraomohyoid (levels I-III): N0 oral cavity SCC
Lateral (levels II-IV): N0 oropharynx, hypopharynx, larynx SCC
Posterolateral (levels II-V): cSCC, melanoma, throid ca
Central (levels VI-VII): thyroid ca
Treatment of thyroglossal duct cyst
Sistrunk procedure
This procedure involve removal of the cyst, midline hyoid & muscular tissue along entire thyroglossal tract
Potential complication of Sistrunk procedure
Bleeding, infection, reaction to anesthesia, scarring
Damage to adjacent structures: superior laryngeal nerve, hypoglossal nerve (rare)
Recurrence: 4% for first operations with Sistrunk, higher if portion of hyoid is not removed
Orocutaneous fistula
Hypothyroidism
Need for postoperative intubation or tracheotomy and NG (feeding) tube
Potential swallowing alteration
