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Hatem Alwagih Neck Mass
Neck Mass Hatem Alwagih
Associate Professor of Surgery
Department of Surgery
Faculty of Medicine
University of Alexandria
[email protected]
Evaluation which leads to the proper treatment and the best outcome
Learning Objectives
1- Describe a systematic method for evaluating patients with neck masses
2- Suggest the appropriate diagnostic studies
3- Discuss differential diagnosis of neck masses
4- Describe the outlines of surgical treatment of neck masses
Classification Neck masses can be originated from: Skin, Endocrine organs, Upper
aerodigestive Tract, Vessels, or Lymph Nodes
They are classified into:
• Congenital
• Acquired
o Inflammatory
o Benign Neoplasm
o Malignant Neoplasm
Evaluation which leads to the proper treatment and the
best outcome follows the following 4 steps: I Appropriate initial assessment
II Role and technique of FNAB
III Appropriate use and interpretation of imaging
IV Management: Importance of specialized multidisciplinary care if malignancy
is suspected
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Hatem Alwagih Neck Mass
I Appropriate Initial Assessment
The correct diagnosis of a lump in the neck can often be made with a careful
history and examination. The clinical signs of size, site, shape, consistency,
fixation to skin or deep structures, pulsation, compressibility, transillumination
or the presence of a bruit still remain as important as ever
• Age
• Location
• Risk Factors
• Symptoms
• Head & Neck Exam
Age
Young Adult
• Congenital
• Inflammatory
• Malignant
Age
Adult ( >40)
• Malignant
• Congenital
• Inflammatory
Pediatric
• Inflammatory
• Congenital
• Malignant
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Hatem Alwagih Neck Mass
Age & Location: The Adult with a Lateral Neck Mass
Location
Angle of Mandible
• Parotid
Central Compartment
• Thyroid
Lateral Neck
• Lymph Node
Age & Location: The Adult with a Lateral Neck Mass
80% Neoplastic
20% Inflammatoryor Congenital
20% Benign
80% Malignant
20% Primary
80% Metastatic
Neck Mass
“Rule of 80’s”
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Hatem Alwagih Neck Mass
Risk Factors
•Sexual Behavior
HPV & HN
• Male predominance Cancer
• Younger patients
• Fewer traditional risk factors
• Sexual behavior as risk factor multiple sexual partners (>6) higher rates of
oro-genital contact with multiple partners
•Sun Exposure
Symptoms of Head and Neck Primary
● Otalgia, unilateral ● Hemoptysis
● Nasal obstruction (snoring) ● Unilateral hearing loss
● Dysphagia ● Epistaxis
● Hoarseness
Symptoms of Lymphoma
● Fever
● Night Sweats
● Weight Loss
Physical Exam What do we need to document?
• Location of the mass in the neck
• Presence/absence of a primary in the head and neck
• Presence/absence of generalized lymphadenopathy
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Hatem Alwagih Neck Mass
Physical Exam
Physical Exam
• Location of the mass in the neck
- Triangles
- Levels
III
III
IVV
Physical Exam
• Location of the mass in the neck
- Triangles
- Levels
III
III
IVV
Physical Exam
• Lymph nodes
- oral cavity
- skin
I I
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Hatem Alwagih Neck Mass
Physical Exam
• Lymph nodes
- oropharynx
II
Physical Exam
• Lymph nodes
- larynx
- hypopharynx
- thyroid
III
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Hatem Alwagih Neck Mass
Physical Exam
• Lymph nodes
-Thyroid
-Below Clavicle
IV
Physical Exam
• Lymph nodes
- nasopharynx
V
Physical Exam
• Presence/absence of a primary in the head and
neck - oral cacvity and oropharynx
Mashberg. Cancer 1973,32:1436-1445
Distribution of
Early Oral Cancer
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Physical Exam
• Presence/absence of a primary in the head and
neck - oropharynx and larynx
Palpation Base of Tongue
Fiberoptic Nasendoscopy
II Role and Technique of FNAB
• Needle size: 25 gauge
• 12-15 Passes should be performed
•Immediate assessment of adequacy by the Pathologist is the rule
FNAB Immunohistochemistry
SCC
Cytokeratin
Positive
Lymphoma
CD45/CD30
Positive
Poorly Differentiated
Malignancy
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Fine Needle
Aspirartion Biopsy
Diagnosis of Lymphadenopathy
• Sensitivity 85-97%
• Specificity 98-100%
• Nondiagnostic 8-16%
• Open Biopsy 22-30%
Role of Open Lymph Node Biopsy
Excisional/Incisional Biopsy may be necessary:
• Sub classification of lymphoma
• Facilitate diagnosis of poorly differentiated carcinoma
• Persistently nondiagnostic FNAB
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III Appropriate use and Interpretation of Imaging
CT
MRI Adults with a lateral neck mass
Assess possible primary
USChildren
Central compartment, all ages
PETMultidisciplinary planning for
select malignant tumours
IV Management: Importance of specialized multidisciplinary care if malignancy is suspected
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Non-malignant neck lumps
1. Cystic hygroma (Lymphangiomas)
• It is a congenital lesion usually present within
the first year of life. (Posterior Triangle)
• Usually remain unchanged into adulthood
• Soft, cystic, multilocular, partially
compressible and brilliantly transilluminant
and may present with pressure effects
• CT or MRI may help define the extent of the
neoplasm
• Treatment of Lymphangiomas includes injection with picibanil or
excision for easily accessible lesions or those affecting vital functions
2 Branchial cleft cysts
• Remnant of branchial cleft (2nd)
• Most commonly occur in the second or third
decades
• Pain +/- (severe throbbing pain)
• Usually presents as a smooth, fluctuant non tender
(tender), non transilluminant mass mobile forwards
and downwards, underlying the anterior border of
the sternomastoid muscle.
• Branchial fistula or sinus
• Primary treatment is with control of infection by antibiotics, followed by
surgical excision.
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3. Thyroglossal duct cyst
• This is a common congenital midline neck mass
• Sometimes at the lateral edge
• Pain and tenderness +/-
• Can be moved transversally but
• Elevates on protrusion of the tongue.
Treatment is with initial control of infection with
antibiotics, followed by surgical excision including the
mid-portion of the body of the hyoid bone (Sistrunk’s
procedure). Occasionally, these lesions become
infected and resolve, or persist following drainage as a
thyroglossal fistula.
4. Lipoma
• Lipomas are the most common benign soft tissue neoplasm in the neck.
They are poorly defined, soft masses usually after the fourth decade.
• They are usually asymptomatic, soft.
• FNAC or MRI Scan can confirm the diagnosis.
• Surgery is indicated when the lump is increasing in size, cosmesis, or
when there is doubt about the accuracy of diagnosis.
5. Sebaceous cysts
• These are common masses occurring often in older people but can occur
at any age.
• They are slow growing, but sometimes fluctuant and painful when
infected.
• Diagnosis is made clinically; the skin overlying the mass is adherent and
a punctum is often identified.
• Excisional biopsy confirms the diagnosis.
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6. Cervical lymphadenopathy
• Acute lymphadenitis
• tender swelling
• Antibiotic trial, less acute inflammatory nodes generally regress in size
over 2–6 weeks.
• If the lesion does not respond, biopsy is warranted
7. TB cervical lymphadenitis
• Upper and middle deep cervical LN
• Onset: gradually
• Pain: +/-
• Systemic symptoms unusual in young
• Abscess (painful, increase size, and skin discoloration )
• Mass: indistinct, firm, matted, fluctuate!
• Temperature!(Cold abscess)
• Treatment with anti TB (6-9 months) Rifampicin Ethambutol INH
Pyrazinamide
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8. Carotid body tumour
• Rare tumour of chemo receptors (40-60 years).
• Slow-growing painless some time pulsating lump
may be bilateral.
• Side to side movement
• Symptoms of transient cerebral ischemia!
• Potato tumors (hard, non tender)
• Palpation may induce vasovagal attack
• Biopsy is contraindicated MRI
• Angiography is the investigation of choice.
• Surgical removal is based on patient factors and
presenting symptoms.
9. Pharyngeal pouch
• Diverticulum of the pharynx through the gap
between the horizontal fibers of the
cricopharyngeus muscle below and the
lowermost oblique fibers of the inferior
constrictor muscle above.
• History of froth and acid taste
• Halitosis regurgitation of food. There is no
bile or to it.
• Pressure on the swelling causes gurgling
sounds and regurgitation
• Treatment: cricopharyngeal myotomy
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10. Ludwig's angina
• Rare but serious connective tissue infection of the floor of the mouth
• Mostly due to dental infections
• Sings of inflammation present
• Treatment: drainage of pus + antibiotic to cover aerobes with anaerobes
11 Thyroid masses
• Thyroid neoplasms are a common cause of anterior compartment neck
masses in all age groups, with a female predominance, and are mostly
benign.
• Fine needle aspiration of thyroid masses has become the standard of care
and ultrasound may show whether the mass cystic.
• Unsatisfactory aspirates should be repeated, and negative aspirates
should be followed up with a repeat FNAC and examination in 3 months’
time.
Characteristics of malignant neck lumps
1. Lymphomas
• Painless lump, non tender smooth and discrete
• Slow growing
• Patient Presented with malaise, wt. loss, pallor.
• Fever, rigor and Hepatosplenomegaly
• Mediastinal mass (SVC syndrome)
• Abdomen pressure on IVC may cause bi lateral leg oedma
• Other lymph nodes in the axilla, groin and abdomen should examined.
• Treatment: according to stage (radiosensitive)
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2. Metastatic Lymph Nodes
• Upper cervical lymph nodes (upper aerodigestive tract).
• Accessory chain of nodes in the posterior triangle (Nasopharyngeal
malignancies).
• (Occult primary) most common sites are tonsil, base of tongue,
nasopharynx and Piriform sinus.
• Virchow's LN (Toisier ’s sign) abdominal and thoracic malignancies
• Painless, non tender, and hard masses
• Work up: Search for primary and deal with it