1. IN THE NAME OF GOD

2. Evaluation and Management of the Patient with a Neck Mass
Dr.mirvakili
Shahid sadoghi university

3. definition
The general definition of a neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles.

4. Anatomy Prominent landmarks Hyoid bone Thyroid cartilage (men)
Cricoid cartilage (women)
Trachea
Sternocleidomastoid muscle

5. Anatomy Triangles of the neck Anterior
Anterior border of the SCM, midline, lower border of the mandible
Subdivisions: inferior carotid, superior carotid, submandibular, submental
Posterior
Posterior border of SCM, clavicle, anterior border of trapezius
Subdivisions: subclavian, occipital

6. General Considerations
Patient age
Pediatric (0 – 15 years): 90% benign
Young adult (16 – 40 years): similar to pediatric
Late adult (>40 years): “rule of 80s”
Location
Congenital masses: consistent in location
Metastatic masses: key to primary lesion

7. General Considerations
Location of mass
Congenital and developmental consistent
Metastatic masses - help identify possible primary
Treat each case individually *

9. Diagnostic Steps History Careful and complete
Developmental time course
Associated symptoms (dysphagia, otalgia, hoarseness)
Personal habits (smoking, alcohol)
Prior trauma, irradiation or surgery

10. Diagnostic Steps Physical Examination Complete head and neck exam
Visualize all mucosal surfaces (direct, indirect)
Palpate oral and pharyngeal surfaces
Emphasize location, mobility and consistency of neck mass (vascular, salivary, nodal, inflammatory, congenital, neoplastic)

11. Empirical Antibiotics
Inflammatory mass suspected
Two week trial of antibiotics
Follow-up for further investigation

12. Diagnostic Tests Fine needle aspiration biopsy (FNAB)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Ultrasonography
Radionucleotide scanning
PET scan

13. Diagnostic Studies Fine needle aspiration biopsy (FNAB)
Standard of care
Indications
Not obvious abscess
Persists following antibiotics
No contraindications (vascular?)
Fine gauge needle ( )
Skilled pathologist critical

14. Diagnostic Studies FNAB continued Needle track seeding not a concern
Bleeding complications reduced
Can be performed in children
Separates neoplasm from inflammatory & carcinoma from lymphoma
Minimum of four separate needle passes

15. Diagnostic Studies Computed Tomography (CT) Very helpful tool
Solid versus cystic
With contrast delineates vascularity
Metastatic masses
Unknown primary and staging purposes
Lucent changes, >1.5 cm, loss of sharpness
Avoid contrast in thyroid masses

16. Diagnostic Studies Magnetic Resonance Imaging (MRI)
Similar information as CT
Better for upper neck and skull base
Infusion may substitute for arteriography

17. Diagnostic Studies Ultrasonography Less important with advent of FNAB
Useful for solid versus cystic (congenital cyst vs. lymph node/glandular tumor)
Noninvasive (pediatric)

18. Diagnostic Studies Radionucleotide Scanning
Intra-glandular versus extra-glandular
Functionality
Salivary and thyroid masses
FNAB preferred for thyroid nodules
Solitary thyroid nodule
Multinodular goiter with new increasing nodule
Hashimoto’s with new nodule

19. Radionucleotide Scanning

20. PET scan Pet scan indicates the functional activity of a mass
A more radio-intense mass has greater metabolic activity and is usually neoplastic
High false positive rate(warthin,s tumor)

22. Nodal Mass Workup in the Adult
Any solid asymmetric mass must be considered metastatic until proven otherwise
Presenting symptom in 12% of cancers
80% are SCCa
History of smoking and alcohol worrisome
Suspicious symptoms and signs
Ipsilateral otalgia with normal otoscopy
Unilateral serous otitis media (nasopharynx)

23. Nodal Mass Workup in the Adult
Indications for panendoscopy
Positive FNAB (staging, search for primary, synchronous primaries - 10 to 20%)
Equivocal or negative FNAB in high risk
Unknown primary
Biopsy suspicious observed areas or suspicious abnormalities on CT/MRI
None - biopsy nasopharynx, tonsil (ipsilateral tonsillectomy for jugulodigastric nodes), base of tongue, and pyriform sinuses

24. Nodal Mass & Unknown Primary
Open excisional biopsy
Repeated exam and workup fail to reveal 10 with an equivocal or negative FNAB
5% of the time
Prepare for complete neck dissection
Frozen section results
Inflammatory or granulomatous: culture tissue
Adenocarcinoma or lymphoma: close wound

25. Common Primary Tumors Thyroid Masses Lymphoma Salivary Tumors Lipoma
Carotid Body and Glomus Tumors
Neurogenic Tumors

26. Thyroid Masses A leading cause of anterior neck masses Children
Most common neoplastic condition
Male predominance
Greater chance of malignancy
Adults
Mostly benign
Female predominance

27. Thyroid Masses Lymph node metastatic 15% of papillary carcinomas
40% with malignant nodules
Histologically in >90% (microscopic)
FNAB is standard of care
Decreases # of patients with surgery
Increases # of malignant tumors found at surgery
Doubles # of cases followed up
Repeat negative aspiration in 1 month

28. Rational approach to Management of a Thyroid nodule

29. Lymphoma More common in pediatric & young adults
80% of children with Hodgkin’s have neck mass
Signs and symptoms
Mass only, fever, hepatosplenomegaly, diffuse adenopathy
FNAB - 1st line; open biopsy if suggestive
CT scans (H&N, chest, abdomen) & bone marrow biopsy

30. Salivary Tumors
Any preauricular enlarging mass or at the angle of the mandible is suspicious
Benign - asymptomatic
Metastatic - rapid growth, skin fixation or cranial nerve palsies
Open excisional biopsy preferred

31. Salivary Tumors
FNAB
Reduces # of patients with surgery by 1/3
Distinguishes intra-glandular lymph nodes, localized sialadenitis, benign cysts
Accuracy >90% (better for benign)
Sensitivity - 90%; Specificity - 80%
May facilitate surgical planning or patient counseling
Prepare for total parotidectomy & nerve sacrifice in unknown primaries

32. Carotid Body and Glomus Tumor
Rare in the pediatric population
Classical presentation
Adult
Pulsatile, compressible mass at carotid bifurcation
Mobile side to side
Diagnosis confirmed by angiography or CT

33. Carotid Body and Glomus Tumor
Treatment
Elderly adult
Observation
Irradiation to arrest growth
Young adult
Resection of small tumors
Hypotensive anesthesia
Preoperative embolization and measurement of catecholamines release

34. Lipoma Over age 35 usually Ill-defined, soft masses
Diagnosis confirmed by excisional biopsy

35. Neurogenic Tumors Peripheral nervous system tumors
Arise from neural crest derivatives
Include schwannomas, neurofibromas and malignant peripheral nerve sheath tumors
Increased incidence in NF syndromes
Schwannomas occur most commonly
MPNST uncommon in head and neck

36. Neurogenic Tumors Schwannoma Benign
Any age, but most common 20 to 50 years
Solitary, slowly enlarging, painless mass
Medial tonsillar displacement
Hoarseness (vagus nerve)
Horner’s (sympathetic chain)
Surgical excision is treatment of choice

37. Congenital and Developmental Masses
Epidermal and Sebaceous cysts
Branchial Cleft Cysts
Thyroglossal Duct Cysts
Vascular Tumors

38. Epidermal and Sebaceous Cysts
Most common congenital mass
Older age group most often
Clinical diagnosis - movement and elevation of overlying skin
Excisional biopsy confirms

39. Branchial Cleft Cysts Late childhood or early adulthood
Often appears rapidly after URI
Skin erythema and tenderness after recent infection
May express purulent material if sinus tract is present
Treatment is initial control of infection, followed by surgical excision

40. Branchial Cleft Cysts 1st branchial cleft cyst 2nd most common
Inferior or angle of the mandible or below the ear lobe
Close association with facial nerve possible
Excision may require total parotidectomy and facial nerve dissection

41. Branchial Cleft Cysts 2nd branchial cleft cyst
Most common
Underlying SCM
Tract courses medial over 12th nerve and between internal and external carotids
3rd and 4th branchial cleft cysts
Rarely reported

42. Thyroglossal Duct Cysts
Most common congenital neck mass
Midline or near-midline mass
Elevates on swallowing or protrusion of the tongue
Differential: lymph nodes, dermoids, ectopic thyroid tissue
Surgical removal (Sistrunk) after resolution of infection

43. Vascular Tumors Almost always present within 1st year
CT/MRI help in diagnosis and defining extent of lesion
Lymphangioma
Remain unchanged into adulthood
Soft, doughy, ill-defined
Treatment: excision for easily accessible or vital function compromise

44. Vascular Tumors Hemangiomas Most often resolve spontaneously
Bluish, compressible
Surgical treatment
Rapid growth
Associated thrombocytopenia
Involvement of vital structures
After failure of medical therapy

45. Inflammatory Disorders
Lymphadenitis
Granulomatous lymphadenitis

46. Lymphadenitis Very common, especially during 1st decade
Marked tenderness, torticollis, trismus, and dysphagia
Systemic signs of infection
Initial treatment - directed antibiotics
Close follow up

47. Lymphadenopathy
Failure of antibiotics necessitates biopsy after complete head and neck work-up
FNAB indications
Progressively enlarging nodes
Solitary, asymmetric nodal mass
Supraclavicular mass
Persistent nodes without infectious signs

48. Lymphadenopathy
Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out lymphoma or granulomatous disease

49. Granulomatous Lymphadenitis
Develop over weeks and months
Minimal systemic complaints or findings
Firm glands, fixation and injection of skin
Common etiologies
Typical Mycobacterium tuberculosis (adults)
Atypical Mycobacterium tuberculosis (children)
Cat-scratch fever (Bartonella henselae) (children)
Actinomycosis, Sarcoidosis

50. Granulomatous Lymphadenitis
Atypical TB
Anterior triangle lymph nodes
Brawny skin, induration and pain
Usually responds to complete surgical excision
Cat-scratch fever
Preauricular or submandibular lymph nodes
Spontaneous resolution 1-2 months
Typical TB (rarely seen, posterior nodes)

51. Summary Extensive differential diagnosis Thorough work-up needed
FNAB invaluable
Malignancy should never be overlooked
Close follow-up and aggressive pursuit of a diagnosis essential

52. Good luck