1. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Presented By : Dr. Farid Al-Zhrani R1 ( ENT )

2. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 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. Definition

3. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass The prominent landmarks of the neck are : 1. hyoid bone, 2. Thyroid cartilage, 3. Cricoid cartilage, 4. Trachea, 5. Sternocleidomastoid muscles.

4. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass The anterior triangle is delineated by : 1. The anterior border of the SCM laterally, 2. The midline medially, 3. The lower border of the mandible superiorly. The SCM divides each side of the neck into two major triangles, anterior and posterior.

5. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass The borders of the posterior triangles are : 1. The posterior border of the SCM anteriorly, 2. The clavicle inferiorly, 3. The anterior border of the trapezius muscle posteriorly.

6. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass The thyroid gland : is usually palpable in the midline below the thyroid cartilage. The parotid glands : are located in the preauricular area on each side in the lateral neck. The tail of each parotid gland extends below the angle of the mandible, inferior to the earlobe.

7. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Submandibular glands : are located within a triangle bounded by …. the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and the body of the mandible. Lymph nodes : are located throughout the head and neck region.

8. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass FIGURE 2. Lymph node groups with the most likely sites of the primary lesion.

9. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 1. History. 2. Physical examination. 3. Investigation. 4. management.

10. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass The evaluation of any neck mass begins with a careful HISTORY. The history should be taken with the differential diagnosis in mind because directed questions can narrow down the diagnostic possibilities and focus subsequent investigations. For example, in younger patients, one would tend to look for congenital lesions, whereas in older adults, the first concern would always be neoplasia.

11. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass the differential diagnosis

12. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * Personal data :- 1. Age. 2. Sex. 3. Nationality. * HPI :- 1. Duration. 2. Location. 3. Size. 4. How notice. 5. Painfull / painless. 6. Other masse. 7. Progression. 8. Trauma.

13. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * Systemic Review :- 1. Symptoms of hypo. OR hyper. THYRODISM. 2. Symptoms which indicate malignancy. 3. Respiratory Symptoms. 4. GI Symptoms. 5. Symptoms which indicate infectious / inflammatory process. ( fever, wt loss, night sweat 6. Head & Neck Symptoms. 7. Compression Symptoms.

14. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * The completion of History : 1. PMH, 2. PSH. 3. FH. 4. Medication & radiation. 5. Social History : smoking, alcohol, contact with T.B. 6. Travel History.

15. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Examination of the head and neck is challenging in that much of the area to be examined is not easily visualized. Patience and practice are necessary to master the special instruments and techniques of examination.

16. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * General Examinations :- 1. Vital Signs. 2. General appearance of the pateint. * Local Examination :- 1. Inspection : a. site. b. shape. c. color. d. relation to deglutition. e. relation to tongue protrusion.

17. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 2. Palpation : a. temperature. b. tenderness. c. size. d. surface. e. edge. f. consistence. g. fluctuation. h. pulsatility. i. relation to skin. j. mobility. k. relation to underlying structures.

18. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 3. Percussion : on the sternum for retrosternal extension of the thyroid. 4. Auscultation : for bruits.

19. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * Complete Head & Neck Examination : 1. look to the head for any mass or ulcer. 2. examine L.N.

20. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 3. examine thyroid. 4. ear, nose & throat examination.

21. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 6. laryngoscope. 5. Mouth examination. 7. esophagi scope.

22. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass * Systemic Examination : 1. Respiratory. 2. GI.

23. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass # Simple : - # Diagnostic : - # Simple : - # Diagnostic : -

24. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 1. CBC :- ( infection, lymphoma ……..etc. ). 2. U/E :- ( Parathyroid ). 3. TFT :- ( Thyroid ). 4. PTH :- ( Parathyroid ).

25. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 5. Calcitonin. Thymoglobulin :- ( Thyroid ). 6. Tuberculine test :- ( T.B. ). 7. CXR :- ( Lung lesions ).

26. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Fine Needle Aspiration Biopsy (FNAB) - # Currently, FNAB is the STANDARD of diagnosis for neck masses. # Indication : Any neck mass that is not an obvious abscess and persists following prescribed antibiotic therapies.

27. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 2. Also may allay patient fears for malignant disease. 3. Helps the clinician differentiate carcinoma from lymphoma, which can prevent unnecessary panendoscopy. # Contraindication : There are NO contraindications to FNAB. # Benefits : 1. FNAB separates inflammatory and reactive processes that usually do not require surgery from neoplastic lesions, either benign or malignant.

28. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass # Miscellaneous : 1. Pulsatile neck masses may represent a carotid body tumor, and although many clinicians prefer not to biopsy these lesions, the fine gauge of the needle reduces bleeding complications. 2. Needle-track seeding of tumor is not a concern with the fine needles used today. 3. FNAB can also be performed in children,

29. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Ultrasonography - With the current accuracy of FNAB, this study has become less important in the work-up of the neck mass. However, it is sometimes useful in differentiating solid from cystic masses and congenital cysts from solid lymph nodes and glandular tumors.

30. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Radionucleotide Scanning – # Benefits : 1. This imaging technique can differentiate a mass from within a gland from one outside a glandular structure. 2. Also indicate the functionality of the mass. 3. This is particularly important for salivary and suspected thyroid gland masses.

31. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Computed Tomography (CT) – # CT scanning of the neck has become a very helpful tool in diagnostically difficult cases. # Benefits : 1. It can distinguish cystic from solid lesions. 2. Define the origin and full extent of deep, ill-defined masses. 3. When used with contrast can delineate vascularity or blood flow.

32. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass 4. In patients with metastatic SCCa to the neck from an unknown primary, CT should be obtained to detect an unknown primary lesion. 5. To help with staging purposes. N.B. : Lucent changes within nodes, size larger than 1.5cm, and loss of sharpness of nodal borders are often signs of metastatic carcinoma.

33. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Magnetic Resonance Imaging – # MRI provides much of the same information as CT. # It is currently better for upper neck and skull base masses due to motion artifact on CT. # With contrast it is good for vascular delineation and may even substitute for arteriography in the pulsatile mass or mass with a bruit or thrill.

34. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass FIGURE. Evaluation and management of a neck mass in the adult patient. (CT = computed tomographic; PPD = purified protein derivative)

35. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass Summary # The differential diagnosis of neck masses is extensive. # Age of the patient is important. # A thorough work-up including an accurate history and complete head and neck examination often :- narrows the diagnostic possibilities, thus obviating the need for excessive testing and invasive procedures.

36. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass # The fine needle aspiration biopsy has become an invaluable tool to aid clinicians in the evaluation of the neck mass and is safe, accurate, and cost-effective with minimal complications. # The possibility of malignancy in any age group, especially in the late adult group. # Close follow-up and aggressive approach is essential to a favorable outcome. Summary

37. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass

38. Dr. Farid Al-Zhrani 6 / 2 /1428 H Approach of the neck mass