neck masses Flashcards
etiologies for neck mass
-squamous cell carcinoma (SCC) - >90%
-alcohol and tobacco- 75%
-HPV (16), betel quid, occupational wood dust, or asbestos, EBV
-pts can develop further associated (secondary) malignancies within following years - 9-23% -> very common
-complications after head/neck cancer: dysphagia, pharyngocutaneous fistula, injury to accessory, vagus, hypoglossal, mandibular nerves
-mocositis or xerostomia (dry mouth) from radiotherapy
diagnosing neck mass
-biopsy
-flexible nasendoscopy (FNE) for direct visualization
-if only presenting with lymphadenopathy -> U/S FNA
-MRI is the imaging of chocie
-CT of neck and chest to look for spreading -> Stages
-PET-CT- first line choice if primary tumor location is unknown
child neck mass
-more likely congenital, inflammatory, infectious
-adults- neck masses > 2cm have >80% malignant
thyroid cancer
-lumps are common- cancer is not
->4cm has increased risk
-lumps are more common in women -> if you find one in men its more chance of cancer
-family hx- 10x increased risk
-usually asymptomatic, compressive sx
-MEN2? past radiation?
-painful? -> most likely an infection
-papillary
-follicular
-medullary
-anaplastic
papillary thyroid cancer
-MC thyroid cancer 75%
-40-50 yo women > men
-multiple lesions
-spread via lymph (bilateral cervical)
-Psammona bodies
-Pupil nuclei - orphan annie eyes- cell
-good prognosis
-tx- total or near total thyroidectomy
follicular carcinoma
-40-60yo women>men
-2nd MC thyroid cancer
-focal encapsulated lesions
-usually hematogenous spread to bones and lungs
-iodine deficiency
-tx- lobectomy
-older pts with >4cm -> total thyroidectomy
-poor prognosis:
-age > 50
-size >4cm
-vascular invasion
-extrathyroidal invasion
-distant metastases
medullary carcinoma
-3% of thyroid cancer
-usually painful
-elevated calcitonin levels !!!
-20% are MEN 2A and 2B syndromes cases
-spread via lymph (cervical) and medullary routes
-monitor calcitonin post op
-distant metastatic ds -> liver, bone, lung
-screen for pheochromocytoma
-tx- total thyroidectomy -> its multicentric
anaplastic thyroid cancer
-rare
-undifferentiated
-painful, hoarse, dyspnea, cough
-skin is warm and discolored over
-older pts (>65) women >men
-very aggressive
-spread by time of presentation 90%
-do neck and chest CT at time of dx
-tx- resection or debulking, chemo
red flags of neck lump
-rapid growth or pain
-pressure symptoms- dysphagia
-cough, hoarse voice, stridor
-multiple enlarged cervical lymph nodes
-tether of lump surrounding structures
-cold nodule (can also be benign)
non-cancerous neck lumps
-benign thyroid adenoma or thyroid cyst
-toxic multi-nodular goiter - hyperthyroidism sx
-non-toxic multi-nodular goiter
-thyroglossal duct cyst*- will move superiorly as pts sticks out tongue
thyroid lump work up
-TFTs- TSH (normal in cancer) and thyroglobulin (used post op- should be undetectable after total)
-toxic/hot nodule- low TSH and high T3/T4 -> low chance of cancer
-high calcitonin- can be medullary carcinoma (use to monitor)
-1. U/S- microcalcifications, hypoechogenicity, irregular margins, increased vascularity -> Red flags
-2. FNA- >1cm, suspicious US, family hx
-radioiodine imaging- tells you if nodule is hot or cold
-bone scintigraphy to further look for metastasis
-1 year after surgery -> fu with serum thyroglobulin level and US
FNA-bethesda scaling
-bethesda scaling
-B1- non diganostic -> repeat in 4-6 weeks
-B2- benign
-B3-4- case by case basis
-B5- surgery
-B6- cancer -> surgery
thyroid cancer management
-chemo, radio, radio-iodine
-ultimately surgical resection
-hemi-thyroidectomy
-total thyroidectomy
-neck dissection- removes lymph nodes
neck surgery complications
-damage to parathyroid -> hypocalcium
-symptoms: paraesthesia or tetany
-check calcium levels after always
-thyroid storm
-hematoma -> airway obstruction
-reopen the wound
-drain and stop bleeding
-ARDS
-cervical sympathetic nerve damage -> horners syndrome - ptosis, miosis (constricted), anhidrosis
-cellulitis, infection
-hypothyroidism and recurrent hyperthyroidism
-ALWAYS HAVE A TRACHEOSTOMY KIT
neck surgery laryngeal nerve injury
-recurrent laryngeal nerve damage -> IPSILATERAL vocal cord paralysis
-unilateral- hoarse voice
-paramedian vocal cords- normal or weak voice
-abducted position- hoarse and ineffective cough
-bilateral- life threatening stridor -> tracheostomy may be needed
-inferior thyroid artery crosses the recurrent laryngeal nerve
-suspensory ligament (ligamentum berry) is near the tubercle of zuckerkandl (lateral part of thyroid gland) -> identifies where inferior thyroid artery feeds in -> and therefore where the recurrent laryngeal
-external laryngeal nerve -> NO hoarseness, difficulty projecting sound, problem for singers
-superior recurrent laryngeal
-2b is most common to cause injury
-nerve injurys can heal
thyroid lymph nodes
-malignant lymph nodes fixed and have tissue in them
pheochromocytoma
-tumor that secrete catecholamines (epinephrine)
-paroxysmal headaches, tachycardia, sweating
-HTN
-MEN2
-prior to medullary thyroid cancer surgery screen for this!!!!
-Plasma metanephrines high -> confirms dx
-tumor follows paraganglionic tissue
-CT, MRI, MIBG -> meta-iodobenzylguanidine (nuclear medicine) -> scan for metastasis
-pre-op tx- alpha-adrenergic blocking agents FIRST (phenoxybenzamine, doxazosin), CCB, BB SECOND
-Use high dose magnesium sulfate → controls BP
-tx- laparotomy surgery, resection
-tie off inferior suprarenal, middle suprarenal a, and superior (inferior phrenic) -> veins too bc once you manipulate the gland it can release catecholamines and cause HTN crisis during surgery
-can cause severe hypotension -> volume replacement, shock, renal failure, seeding of tumor
-control glucose -> can have hypoglycemia
-insufficient cortisol
-bleeding
-infections, UTI, lung infection
-blood clot in leg
-Adverse reaction to anesthesia:
-give Cortisol -> upregulates alpha receptors → without this BP drops
-If resistant to pressures – give steroids –> replace what they are not getting (mineralocorticoids like aldosterone)
MEN syndromes
