Evaluation and Management of the Patient with a Neck Mass Bastaninejad, Shahin, MD, and HNS Specialist ORL Anatomy History and P.Exam. Historical Points • Age: – Up to 15yrs (pediatrics) more than 90% benign – 16 to 40 (young adult) – More than 40yrs (older adults) 80% neoplasm 80% of them malignant (secondary>>primary) • Time course • immunodeficiency • Prior trauma • Travel, Irradiation, Surgery • Associated symptoms fever, dysphagia, weight loss, otalgia, hearing loss, respiratory difficulties • Perform a FULL head and neck examination Diagnostic imaging Table 116-1 -- Imaging of Neck Masses Modality Basic Indications Ultrasound Good for pediatric neck masses, thyroid masses. Differentiates cystic versus solid. Computed tomography Workhorse imaging modality for adult neck masses. Provides three-dimensional relationships, excellent detail of mucosal disease and involvement of adjacent bone. Magnetic resonance imaging Superior soft tissue delineation. Good for lesions of the salivary glands and tongue (where dental amalgam may obscure the view on a CT). Modality of choice for determining nerve enhancement. Consider for thyroid imaging in cases necessitating radioiodine. Radionuclide scanning Useful for midline lesions in children—differentiates functioning from nonfunctioning tissue. Positron emission tomography Useful for staging of head and neck malignancies. Can be used in cases of unknown primary malignant neck masses or treated neck disease. Angiography/magnetic resonance angiography/computed tomography angiography Plain radiograph Useful for lesions encasing the carotid and vascular lesions. Conventional angiography should be considered for preoperative assessment in cases of potential carotid artery sacrifice or where embolization is required. Generally should not be considered in the workup of a neck mass. Initial w/u of the unknown neck mass • FNA if unsuccessful or less informative consider Re-FNA failure again consider core needle Bx Failure again excisional Bx and if it was SCC, consider simultaneous neck dissection procedure Differentials for Unknown neck mass Inflammatory causes • The most common neck masses • LAP: – typically subside without tx – sometimes it become necrotic and an abscess forms (Staph./Strep.) • Granulomatous disease: TB, atypical mycobac., actinomycosis, cat scratch, syphilis. – FNA better than excision (because of the risk of nonhealing wound) • Sialadenitis and Sialolithiasis – Abx – Hydration – Warm compresses – Massage – sialogogues Congenital neck masses • TGDC – In pediatric they are second in frequency only to LAP – Elevates in the neck with tongue protrusion – If it becomes infected: Avoid I&D Choice is Aspiration and Abx. – Main procedure is Sistrunk procedure • Branchial cleft anomalies – Anomalies: cyst, sinus, fistula – 30% of the pediatric neck masses – 95% of them 2nd Arch anomaly: • Manifest as a lateral neck swelling associated with an URI • Like TGDC, avoid I&D • Tract pathway is lateral to the ICA, and enters to the pharynx at the tonsillar fossa • Its swelling bulk or draining tract is anterior to the SCM muscle • 1st Branchial Cleft anomaly – 1% of branchial cleft anomalies – Associated with VII nerve – Fistula, cyst & sinuses located between EAC and the angle of the mandible • Type 1: EAC duplication, contain ectodermal elements, it’s lateral to the VII nerve • Type 2: Contain ectodermal and mesodermal elements (mesocartilage), it’s deep to the VII nerve • 3rd and 4th BCA – Extremly uncommon – Swelling or sinus tract in the lower neck, anterior to the SCM muscle – 3rd: Deep to the CA, pierce thyrohyoid membrane and enters the pharynx at pyriform sinus – 4th: Deep to the CA, close to the thyroid gland, enters pyriform sinus or cervical esophagus • Dermoid cyst: contains ectodermal and endodermal elements • Teratomas: – all three germ layers – Less than 2% of all body teratomas are in H&N, most commonly: neck and nasopharynx • Lymphangioma most common in posterior triangle • Hemangioma: – Commonly occure in H&N and it’s present at birth – Phases: • Rapid expansion (6-12mo) • Stable phase; no/minimal change occures • Involution; usually begins by 24mo – 50% complete in 5yr age – Nearly all tumors regress by 10-12yr s age Neck Neoplasms Primary neoplasm of the neck • Lymphoma: – Most common H&N malignancy in Ped. – 2nd most common overall H&N malignancy second only to SCC (SCC is the most common H&N cancer) – Non Hodgkin (*5) > Hodgkin – 90% B cell • Thyroid neoplasm: – Most common neoplastic anterior neck masses in all age groups – More than 90% of all thyroid nodules are benign • Malignancy probability is greater in very young children, very old age population and males • Salivary gland neoplasm – 1% of all H&N masses – MEC is the most common salivary malignancy • Salivary gland neoplasm, Continue: • %80 is from parotid gland %80 benign majority: benign mixed tumor • %15 SMG %50 malignant • %5 S.Lingual & minor glands More than %75 malignant – Neurogenic Neoplasm: • Schwanoma – Is the most common neurogenic tumor – Parapharyngeal space is a common location • Neurofibroma – There is a %2-6 risk of malignant degeneration (malignant nerve sheet tumor) • Neurogenic Neoplasm, Continue: – Neuroblastoma, ganglioneuroblastoma, . . . – Neuroma it is a complication of truma, mainly greater auricular nerve • Paraganglioma neuroectodermal origin – Carotid body (angiographyLyre’s sign) – Jugulotympanic region usually not a neck mass – Vagus nerve • Lipoma Work up for Unknown Primary, SCC of the Neck 1. complete physical examination (inspection and palpation) of all head and neck subsites Oral cavity Oropharynx Thyroid Salivary glands Face/scalp/neck skin 2. Fiberoptic endoscopy examination Nasal cavity Nasopharynx Oropharynx Hypopharynx Larynx 3. Fine-needle aspiration Table 116-2 -- Steps in the Workup of an Unknown Primary Squamous Cell Carcinoma of the Neck 4. Primary imaging Head and neck (computed tomography or magnetic resonance imaging) Chest (radiograph or computed tomography) 5. Secondary imaging Positron emission tomography 6. Panendoscopy/ Directed mucosal site sampling Include laryngoscopy, bronchoscopy, esophagoscopy, and ipsilateral tonsillectomy. Pay close attention to the tongue base and hypopharynx.