management of neck mases
TRANSCRIPT
An Approach to Patients with a Neck Mass
By Dr Alihussein kassamIntern doctor
Mnazi mmoja hospital,zanzibar
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Introduction
• Common clinical finding• All age groups• Very complex differential diagnosis• Systematic approach essential
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What will one think of?
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Anatomical Considerations• Prominent landmarks
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General Considerations
• Patient age– Pediatric (0 – 15 years): 90% benign– Young adult (16 – 40 years): similar to pediatric– Late adult (>40 years): “rule out CANCER”
• Location– Congenital masses: consistent in location– Metastatic masses: key to primary lesion
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Metastasis Location according to Various Primary Lesions
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Diagnostic Steps
• History
• Physical Examination
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Empirical Antibiotics
• Inflammatory mass suspected• Two week trial of antibiotics• Follow-up for further investigation
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Diagnostic Tests
• Fine needle aspiration biopsy (FNAB)
• Computed tomography (CT)
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Fine Needle Aspiration Biopsy
• Standard of diagnosis
• Indications
• Small gauge needle
• No contraindications (vascular ?)
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Fine Needle Aspiration Biopsy
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Computed Tomography
• Distinguish cystic from solid• Extent of lesion• Vascularity (with contrast)• Detection of unknown primary (metastatic)• Pathologic node (lucent, >1.5cm, loss of shape)
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Ultrasonography
Role of U/S is limited,
“Why do an ultrasound if you can palpate?”
Dr Naufal kassim
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Nodal Mass Workup in the Adult
• Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise
• Asymptomatic cervical mass – 12% of cancer• ~ 80% of these are SCCa
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Metastatic neck disease
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Metastatic neck disease
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Metastatic neck disease
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Primary Tumors
• Thyroid mass• Lymphoma• Salivary tumors• Lipoma
• Carotid body and glomus tumors
• Neurogenic tumors
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Thyroid Masses
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•Do all thyroids with a pathology enlarge?
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Lymphoma
• More common in children and young adults• Up to 80% of children with Hodgkin’s have a neck mass• Signs and symptoms– Lateral neck mass only (discrete, rubbery, nontender)– Fever– Hepatosplenomegaly– Diffuse adenopathy
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Lymphoma
• FNAB – first line diagnostic test• If suggestive of lymphoma – open biopsy• Full workup – CT scans of chest, abdomen, head and
neck; bone marrow biopsy
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Lymphoma
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Salivary Gland Tumors
• Enlarging mass anterior/inferior to ear or at the mandible angle is suspect
• Benign – Asymptomatic except for mass
• Malignant– Rapid growth, skin fixation, cranial nerve palsies
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Salivary Gland Tumors
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Carotid Body Tumor
Rare in childrenPulsatile, compressible massMobile medial/lateral not superior/inferiorClinical diagnosis, confirmed by angiogram or CTTreatment
Irradiation or close observation in the elderlySurgical resection for small tumors in young patientsHypotensive anesthesiaPreoperative measurement of catecholamines
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Carotid Body Tumor
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Lipoma
• Soft, ill-defined mass• Usually >35 years of age• Asymptomatic• Clinical diagnosis – confirmed by excision
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Lipoma
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Congenital and Developmental Mass• Epidermal and sebaceous cysts• Branchial cleft cysts• Thyroglossal duct cyst• Vascular tumors
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Epidermal and Sebaceous Cysts
• Most common congenital/developmental mass• Older age groups• Clinical diagnosis– Elevation and movement of overlying skin– Skin dimple or pore
• Excisional biopsy confirms
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Epidermal and Sebaceous Cysts
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Branchial Cleft Cysts
• Branchial cleft anomalies
• Present in older children or young adults often following URI
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Branchial Cleft Cysts
• Most common as smooth, fluctuant mass underlying the SCM
• Skin erythema and tenderness if infected• Treatment– Initial control of infection– Surgical excision, including tract
• May necessitate a total parotidectomy
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Branchial Cleft Cysts
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Thyroglossal Cyst
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Thyroglossal cyst
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Vascular Tumors
• Lymphangiomas and hemangiomas• Usually within 1st year of life• Hemangiomas often resolve spontaneously, while
lymphangiomas remain unchanged• CT/MRI may help define extent of disease
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Vascular Tumors (lymphangioma)
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Vascular Tumors (hemangioma)
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Vascular Tumors
• Treatment– Lymphangioma – surgical excision for easily accessible or
lesions affecting vital functions; recurrence is common– Hemangiomas – surgical excision reserved for those with
rapid growth involving vital structures or associated thrombocytopenia that fails medical therapy (steroids, interferon)
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Inflammatory Disorders
• Lymphadenitis• Granulomatous lymphadenitis
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Lymphadenitis
• Very common, especially within 1st decade• Tender node with signs of systemic infection• Directed antibiotic therapy with follow-up
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Lymphadenopathy
• Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease
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Granulomatous lymphadenitis
• Infection develops over weeks to months• Minimal systemic complaints or findings• Common etiologies– TB, atypical TB, cat-scratch fever, actinomycosis,
sarcoidosis• Firm, relatively fixed node with injection of skin
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Granulomatous lymphadenitis• Typical M. tuberculosis– Usually responds to anti-TB medications– May require incisional biopsy for further workup– Chest X-ray ? Important?– Skin test?
• Symptoms– Low grade fever– Night sweats– >10% weight loss
• Signs– Persistence fistula following I & D
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Summary
• Extensive differential diagnosis• Age of patient is important• Accurate history and complete exam essential• FNAB – invaluable diagnostic tool• Possibility for malignancy in any age group• Close follow-up and aggressive approach is best for
favorable outcomes
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