Management of Neck Lumps

Slides:



Advertisements
Similar presentations
Approach to a Patient with Lymphadenopathy
Advertisements

Adult Neck Masses Justin Dumouchel 9/14/05.
Surgical Thyroid Disease. Surgical Thyroid disease Presentation and assessment Indications for surgery Risks of surgery Thyroid cancer / RAI protocol.
EDWARD WEISBERGER MD OTOLARYNGOLOGY/HEAD AND NECK SURGERY INDIANA UNIVERSITY MEDICAL CENTER.
Cancer -uncontrollable or abnormal growth of abnormal cells.  *1st leading cause of death is a heart attack  *Cancer is the 2nd leading cause of death.
Neck Swelling Differential Diagnosis
Renal Tumours n Mr C Dawson MS FRCS n Consultant Urologist n Fitzwilliam Hospital n Peterborough.
First HAYAT Annual Patients Forum – 21 st March 2010 – SAS, Kuwait First HAYAT Annual Patients Forum 21 st March 2010 Al Hashimi II Ballroom – SAS Hotel.
Thyroid nodule History History Physical examination Physical examination –Euthyroid –Hypothyroid –Hyperthyroid Labs Labs –TSH –(antibodies)
Head and Neck Conditions
Update in the Management of Thyroid Neoplasms University of Washington
THYROID GLAND.
Supporting the oral cancer patient – what is the role of the dental team? Karen Matley Catherine Waldon Patient Involvement in Service improvement groups,
Bowel Cancer Alex Hill. Why screen for bowel cancer?  Bowel cancer causes deaths per yr  It may be detected at asymptomatic stage by simple, safe.
Dr. Mohamed Selima. The tongue is a mobile muscular organ can assume a variety of shapes and positions. The tongue is partly in the oral cavity and partly.
ד"ר חגי מזא"ה כירורגיה אנדוקרינית מבואות כירורגיה שנה ד'
Approach to a thyroid nodule
Approach to the Thyroid Nodule
Acinic Cell Carcinoma of the Parotid Gland Metastatic to the Epidermis of the Back Pilcher R. Davidson MJC. Department of Oral and Maxillofacial Surgery,
2010  Solitary thyroid nodules are present in approximately 4 percent of the population.  Thyroid cancer has a much lower incidence of 40 new cases.
In the name of God Isfahan medical school Shahnaz Aram MD.
Endocrine Pathology Lab
Oral cavity The majority of tumors in the oral cavity are s.c.c.
Managing a swelling in the thyroid Mark Lansdown Leeds Teaching Hospitals Trust.
 Previous batches recommended to read the Examination from browse starting from page 270,especially the special test of thyroid, and the examination of.
IMAGING OF THE THYROID Dr Jill Hunt Consultant Radiologist West Herts NHS Trust.
Introduction of Fine Needle Aspiration (for cytotechs) By Dr May Yu 3rd August 07.
Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Presented By : Dr. Farid Al-Zhrani R1 ( ENT )
Cancer: Uncontrolled Cell Growth
Evaluation of Thyroid Nodules
NECK MASSES.
Cancer – A general term for more than 250 diseases characterized by abnormal and uncontrolled growth of cells.
Breast Cancer. Breast cancer is a disease in which malignant cells form in the tissues of the breast – “National Breast Cancer Foundation” The American.
 What is cancer? How do cancer cells differ from other cells?  Do you know of any types of cancer? If so…name them.
Case scenarios- Neck Swelling
Question No.1 If you were the physician who initially saw the patient four years ago, what would you have done?
1. Clinical Impression? Differentials?. Thyroid Carcinoma commonly manifests as a painless, palpable, solitary thyroid nodule The patient's age at presentation.
Thyroid disease By Dr Fahad.
1. What is your clinical impression?. Differential Diagnosis TB adenopathyLymphoma Lymphadenitis from aphthous ulcer Metastatic carcinoma from oral cavity.
Neck Masses Mohammed Mazhar Beddawi Raed Zakaria Al Bog Ahmmed Zaid Al Sabag.
Management of thyroid nodule.  Introduction.  Guidelines recommendation.  Thyroid nodule work up.  Medical therapy in thyroid nodule  Thyroid nodule.
Consultant Obstetrician & Gynaecologist
It is essential to obtain the exact history of the hypersalivation as well as a thorough and complete past medical history. Oral evaluation should be performed,
Differential diagnosis of head and neck swellings
Lung Cancer WHAT IT IS & WHAT YOU NEED TO KNOW. What is lung cancer? 2 types: 1. Non-small cell lung cancer (NSCLC). 85% of cases 2. Small cell lung cancer.
Sjogren’s syndrom  It is an autoimmune disease causing destruction of the salivary and the lachrymal g  Either primary or secondary to C T disease.
Outcomes Following Urgent Referral for Head & Neck Ultrasound Dr Anna ffrench-Constant Dr Mandy Williams.
Submandibular gland: Surgical Anatomy Tumors Surgery
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound Consensus Conference Statement Radiology 2005; 237: Presented.
Haematuria Haematuria is a common condition and one which must be taken seriously. Haernaturia is usually divided into :- - Macroscopic (where the urine.
Ectopic Thyroid Gland Intern 陳君豪 2005/08/22.
BREAST CANCER Walid Galal El Shazly
Chapter 3 Neoplasms 1.
COmmon Neck swellings Dr Mohammad AlShehri, Can. Board, FACS, D Med Edu. Professor of Surgery.
NECK MASSES.
Male and Female Reproductive Health Concerns
Cancer Cancer – A general term for more than 250 diseases characterized by abnormal and uncontrolled growth of cells.
CLINICAL BREAST EXAMINATION
Dr. Sura Obay Al-Dewachi
Testicular Cancer.
National Oesophago-Gastric Cancer Audit 2018 Annual Report: Slide set
Handling and Evaluation of Breast Cancer Biopsy
Statistics (from the National Institutes of Health)
Solitary Thyroid Nodule Aisha Abu Rashed
1.6 U.6 Mutagens, oncogenes and metastasis are involved in the development of primary and secondary tumours. Tumours are abnormal growth of tissue that.
Introduction of Fine Needle Aspiration (for cytotechs)
Presentation transcript:

Management of Neck Lumps David Howe Consultant ENT Surgeon Heart of England Foundation Trust Spire Parkway

What to cover? Common neck lumps What the likely pathology is Initial investigations and management Red Flags

How to approach assessment History - consider age of patient Duration of mass, has it changed? Pain ? referred Associated symptoms eg swallowing/voice issues Risk factors eg smoking, immunosuppression, previous RT

Location of key structures Thyroid Major salivary glands Lymphatic groups Thyroglossal duct cysts Branchial cysts Dental sepsis Direct spread of tumours

Mandatory Anatomy slide!!

Salivary lesions Glands in order of frequency Parotid Submandular then Sublingual Minor salivary Rates of malignancy affected by gland type Parotid lesions approximately 80% benign Submandibular gland and others 50% risk of malignancy

Parotid Commonly pleomorphic adenoma circa 60% Has small risk of malignant potential Hence patients offered surgery (also to confirm pathology) Warthins tumours - entirely benign, common in smokers and often bilateral, tail of parotid. Malignancy, primary or met (often from skin e.g. scc) Prognosis and treatment dependant on grade of tumour

Submandibular masses Most common site for a calculus Often show up on uss but sometimes requires ct Treatment options - conservative, endoscopic, open Tumours, benign generally a PA, remember 50% rate of malignancy. Assess with USS and probably FNA Surgery generally primary treatment.

Minor salivary lesions Generally noticed on per oral inspection - often by the patient. I would suggest refer in as they need biopsy (60-80% malignant) Floor of mouth swelling around submandibular duct could be a calculus or a sublingual tumour or ranula.

Dental Sepsis Increasingly common!! Dearth of NHS dentistry Patients presenting with deep space neck infections and swellings under mandible Particularly consider this in submental swellings and those with discharge Look at teeth, consider OPG and dental review Often need tooth removing to resolve problems

Branchial cyst Common presentation of sudden swelling in level 2/3 of neck Occurs in late teens and early 20’s Can occur later in life but in age over 40 consider possible sinister causes. Recommend referral and removal if indicated or wanted.

Younger age group, benign lesion ? cystic degeneration of lymph node. Over 40’s likely to be benign, but possibility of cystic metastasis from a SCC Therefore more extensive workup in higher risk group and often pet scan undertaken Objective to identify potential primary lesion and avoid surgery to neck unless therapeutic. Definitely consider 2WW referral for these, particularly in over 40’s Most turn out to be benign, very rarely a cystic metastasis from a thyroid cancer

Lymph nodes Can be difficult sometimes to prove there is nothing of concern Worries about over/under investigating Possible risk of not identifying a low grade/quiescent lymphoma Limitations of both imaging/biopsy/clinical assessment Risks of lymph node biopsy not inconsiderable

Consider Age Duration and associated symptoms Risk factors Size definitely matters!!!! Location of nodes is important, particularly supraclavicuar and posterior triangle Careful assessment of throat and ask about pain/swallowing issues etc as patient may not volunteer them

Investigations Could simply refer If low risk/clinical concern Baseline bloods/USS How long to allow to improve?? Patient anxiety

USS of lymph nodes Operator dependant!! Description sometimes difficult to lead management. But - a reactive node should retain a fatty hilum, be ovoid in shape and have a normal vascular pattern despite being enlarged Morphologically abnormal nodes need further investigation, sometimes reactive nodes can look like this and subsequently improve.

Role of referral Allows nasoendoscopy and comprehensive assessment of throat Consideration of fna May require open lymph node biopsy Limitations of fna in neck nodes, may give an indication of high grade lymphoma but not diagnostic and either a core biopsy or open biopsy needed. Can infer if likely to be granulomatous e.g. TB Node maybe related to either a systemic metastasis or unknown primary lesion

Unknown primary Carcinoma in lymph node with no primary evident May be head and neck primary levels 1-4 Distant primary more likely in supraclavicular node - lung/bowel/renal etc Role of cross sectional imaging and PET scan Head and neck primary often an occult tonsillar tumour or tongue base primary

Thyroid Nodules Thyroid Nodules are very common circa 45% of female population age over 50 have thyroid nodules Malignancy relatively rare. 2010 Annual incidence in the UK 5.1 per 100,000 women cf 2.3 in 1971-95 (Cancer Registry) 900 new cases and 250 deaths recorded in England and Wales per year

Most common endocrine malignancy Only 1% of all malignancies Increasing incidence of PTC - much of this incidental micro papillary carcinoma (<1cm) or lower stage cancers Overall mortality from thyroid cancer unchanged for many years

In Primary Care - What do USS reports mean USS report should hopefully recommend referral to a specialist if there are concerning thyroid lesions. Potential difficulty if report has no explicit U classification and simply descriptive text regarding echogenicity of nodules - what does that mean??? Strong family history/previous radiation exposure High TSH - association with increased risk of cancer Suggest - U2 nodules and euthyroid probably don't require investigation -subjective U3 upwards need referral as per 2WW Compressive symptoms/goitre - consideration for decompressing surgery

Does size matter?? Historically as the size of the nodule increased in size the reliability of biopsies and scans reduced. Probably minimal increased risk of cancer just uncertainty This still applies

Imaging is key to investigation of nodules

New Guidelines Aim of guidelines - to reduce unnecessary investigation cost - lots of nodules, most benign Big cost implication for healthcare system Thyroid Nodules are now classified based on USS Appearance Low risk (benign lesions) - U1/U2 considered benign No further investigation needed Higher risk U3/U4/U5 progressive increasing risk of cancer Require a biopsy and possibly surgery Introduced in 2014 New system - entirely dependant on radiology opinion. Subjective interpretation of USS findings - need to consider thyroid specialist radiologist Reclassification of USS appearance frequently at mdt - important as this can determine if a biopsy is even done!

Indications for Surgery Concern regarding malignant nature of nodule Compressive consequences of a large goitre - normal tracheal compression Thyrotoxicosis Cosmetic - not generally recommended although often requested!!!

Case Study 40 year lady Neck lump incidental No family history What next?

History Often of minimal influence in thyroid management Strong FHx/radiation exposure Voice change very rare even with malignancy Haemoptysis -very rare Compressive symptoms? Symptoms of thyroid dysfunction

Investigations Bloods TFTs - if toxic consider endocrine referral - maybe a toxic nodule (low chance of malignancy) Thyroid antibodies - helpful for interpretation of uss and biopsy findings (pseudo tumour)

Ultrasound USS finding 3cm hypo echoic, well defined nodule, some intralesional vascular flow (U3). Rest of thyroid normal What next?

Management - will require biopsy - therefore refer USS FNA FNA scored Thy 1 -5 -needs MDT review This lesion thy 3f (unable to refine between benign and malignant lesions) Therefore offer diagnostic lobectomy Risk of malignancy approximately 25% in this situation

Thyroglossal duct cyst Commonest in childhood and young adults Can be complicated by infection Malignancy very rare but reported Investigation of choice - use Check for normal thyroid tissue Surgery not essential

Acute swellings Lymph nodes - probably inflammatory, can become necrotic and form an abcess particularly in infants ? I&D Thyroid cysts - spontaneous bleed and swell ? coughing fit Deep neck infection, potential life threatening!!! From quinsy, fb or dental source typically Often need ITU or tracheostomy and agressive Abx therapy

Summary Position of neck lump informs likely pathology Risk factors key Consider red flags - pain, voice change, swallowing, B symptoms Early referral suggested if concern (2WW) USS often helpful first line investigation