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ENT

HEAD & NECK TUMORS


2nd Shifting/September 23, 2010
Gatongi, Ngwenya, Gitau, Lafong, Hasan, Madhu-Nagpal

Common neck masses  If the mass is slow growing, it is more likely to


A. Neoplastic be benign
1. Metastatic 2. Associated symptoms
a. Unknown primary CA  Change in voice, swallowing, pain etc.
b. EPidermoid Ca 3. Personal habits
2. Primary head and neck  Prolonged use of tobacco, algohol
a. Epidermoid CA 4. Past history
b. Melanoma  Trauma, irradiation, surgery
3. adenoCA
4. lymphoma PHYSICAL EXAM
5. salivary CA 1. Direct and indirect visualization
6. lipoma  All mucosal surface
7. angioma 2. Palpation
8. carotid body tumor  Palpate the oral cavity and neck
9. rhabdomyosarcoma 3. Sensory
 Odors and bruit
B. Congenital and development
1. Sebaceous cyst DIFFERENTIAL GROUPINGS
2. Brachial cleft cyst  Vascular
3. Thyroglossal duct cyst  Salivary
4. Lymphangiopma/hemangioma  Nodal
5. Dermoid cyst  Inflammatory
6. Ectopic thyroid tissue  Congenital
7. Laryngocoele  Neoplastic
8. Pharyngeal diverticulum
9. Thymic cyst CLINICAL THERAPEUTIC TESTING
“antibiotic usage”
C. Inflammatory  Where is inflammation suspected?
1. Lymphadenopathy
 Duration should not exceed 2 weeks
a. Bacterial
b. Viral  Follow up exam is mandatory
c. Graniulomatous
2. Tuberculous FNAB
3. Cat scratch 1. Current standard care
4. Sarcoidosis 2. Use small gauge needle (20), (book: 23-25)
5. Siladenitis 3. Requires proper collection
6. Congenital cysts  Slide prep
 Skilled cytopahologist
INITIAL CONSIDERATION 4. On site review is most effective
1. In ped patient ages 0-15
 Inflammation> congenital> neoplastic IMAGING STUDIES
2. In young adults 16-40 1. UTZ
 Inflammation>neoplastic>congenital  Differentiates solid from cystic masses
3. In adult ages >40 2. Radionuclide scan
 Neoplastic> inflammation>congenital  Locates mass within/outside the gland
 Glandular functional info
HISTORY 3. Sialography
1. Time course progression 4. Plain film xrays
 If the mass is fast growing, it is more likely to 5. CT/MRI- neural structure
be malignant  Most comprehensive single test
 Can determine solid vs. cystic lesion

ANYA DYOSANG PIPAY FAIFAI WEB JOJO ARLS JESS AYKI JAM KRISETTE ELYSSE KEKE KARING MIKKO YEL EM BOK SHENG ANNE KRISTINE KUKIS CYNTHIA
KIWI NATHAN MIGGY MAYEE MACOY BONI ROD JEANS KATHY PENG BABY JI HOO CHACHA JAJA DEE AILA JERMIE CATH OJ MAI POYENG DET ELAINE
FAYE REUBEN LULU LELE YIMMY LEE THEA JEN MEYMEY DIA ANNE CRISTINE MAIKA MARC GELIQ DOP BEDA YEN
Medical Therapeutics
MALIGNANT HYPERTHERMIA
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 Provides information on the location of the 4. Supraclavicular nodes – lung, GIT, GUT
mass whether nodal or glandular
 Provides info on the vascularity of the mass SPECIFIC NECK MASSES
(with infusion) I. Primary neoplastic neck masses
 Nodal malignancy – lucency, size, indistinct
border 1. THYROID NEOPLASM
 Anterior compartment masses
ULTRASONOGRAPHY PATTERN  In children/young adults – most common,
1. Complex pattern with male preponderance & higher incidence
 Differentiate abscess or necrotic tumor of malignancy
clinically  In older age group – has female
2. Cystic preponderance and mostly benign
 Differentiate lymphoma and hyperplastic  Lymph node metastases
node by A-mode testing or aspiration o 15% initial symptoms in papillary Ca
3. Solid o 40% of malignancies have nodes
 Differentiate crystalline or colloid cyst by A- when operated
mode pattern or aspiration (90-95% accurate)  Tests:
o Scan/UTZ
BASIC PATTERN o FNA
1. Undiagnosed neck masses in an adult are metastatic
carcinoma until proven otherwise 2. SALIVARY NEOPLASM
a. According to the study of Martin & Romies – neck  Consider any preauricular or angle of
mass is the first symptom in CA in 12% of 1300 mandible mass until proven otherwise
cases  Benign masses are asymptomatic
b. Accdg to Hayes Martin – asymmetric enlargement  Malignant if there is/are:
of one or more cervical lymph nodes in an adult is o Rapid growth
almost always cancerous and is visually due to o Nerve palsy
metastases from a primary lesion in the mouth or o Skin fixation
pharynx  Tests:
c. Results of 163 lymph node biopsies o Scan – little help in dx
 29.4 % epidermoid CA o Sialography –helps in locating the
 21.4% lymphoma or hodgkins mass
 10.1% benign hyperplasia
2. Excisional biopsy of a mass in an adult prior to a 3. CAROTID BODY TUMOR
complete head and neck evaluation is contraindicated  During PE
 Primaries foung on the initial examination o There is presence of thrill bruit
o Memorial – 218 patients – 65% o Compressible refills
o MD Anderson – 259 patients – 52% o Moves side to side NOT up and down
 Diagnosis – ARTERIOGRAM
FNA APPLICATION o Demonstrate a characteristic highly
1. Anterior compartment thyroid mass treatment vascular mass at the carotid
decision bifurcation
2. Differentiate cystic from solid lesions  Found in older age groups
3. Confirm metastases from distant known primaries  Elevates and moves with the skin
4. Establish diagnosis in non-surgical head and neck
patient 4. BRACHIAL CLEFT CYST
5. Allay patient fear of cancer – aloows informed
 Onset: late childhood or early adulthood and
observation of hyperplastic nodes
follows upper respiratory infection
6. Differentiates carcinoma from lymphoma – prevents
 Location: anterior triangle of the neck
endoscopy
 Tests: UTZ – cyst
 TX:
GUIDED BIOPSY SITES
o Control initial infection
1. Posterior cervical nodes – nasopharynx
o Avoid incision and drainage
2. High and mild jugular nodes – tonsil
3. Mild jugular nodes – tongue base, pyriform sinus o Total tract incision
o
Medical Therapeutics
MALIGNANT HYPERTHERMIA
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5. THYROGLOSSAL DUCT CYST 3. Single asymptomatic nodal mass


 Onset: childhood and follows URTI 4. Persistent nodal mass without antecedent
 Location: midline of the neck active infectious sign
 Tests: 5. Nos. 1 to 3 only after a complete head and
o Tongue protrusion neck work-up especially in adults.
o Scans
o UTZ Pediatric Lymph Node Biopsy
 Treatment: (Knight et al. 234 patients)
o Control initial infection  40% specific diagnosis
o Avoid incision and drainage  16% malignancy overall
o Remove by Sistrunk procedure  60% malignancy in supraclavicular site
*because of the intimate association of the
thyroglossal duct with the hyoid bone it is III. PEDIATRIC NECK MASS
mandatory to remove simultaneously the central  Concept of repeated examinations
portion of the bone
 Indications for biopsy
6. LYMPHANGIOMA 1. Solitary mass
 90% of masses present in the first year of life 2. Asymmetric mass
 Posterior triangle of the neck 3. Supraclavicular mass
 PE 4. Progression of size
o Soft, fluctuant mass 5. Other historical/physical markers
6. Positive or equivocal FNA
o Transilluminates
 Treatment: resection – only if it does not
A. GRANULOMATOUS LYMPHADENITIS
mutilate, if easily accessible and vital
a. M. tuberculosis (atypical)
structures are not compromised
 Found in pediatric age group
 Discrete nodes
7. HEMANGIOMA
 Found in anterior triangle nodes of the neck
 Onset: usually present at birth or at 1st year of
b. M. tuberculosis (typical)
life
 True TB
 Types:
 More common in adults
o Capillary
 Found in posterior triangle nodes of the
o Cavernous
neck
o Mixed
c. Sarcoidosis
 Signs: compressible, bluish discoloration,
d. Actinomycosis
increased warmth
 More common in adults
 Treatment:
 Associated with dental infection
o Observation (usually)
 Occurs in submandibular and upper jugular
o Surgery only if:
nodes
 Rapid growth beyond one
e. Cat-scratch disease
year
 Predominance in pediatric age group
 Thrombocytopenia
 Single node: tender and inflamed
 Vital structures are
 Occurs in preauricular and submandibular
threatened
nodes
 Resolves spontaneously
8. DERMOID CYST
f. Histoplasmosis
 Unlike epidermal cyst, dermoid cyst lie deep
g. Toxoplasmosis
to the cervical fascia – skin moves over them
 Location: similar to location of brachial cleft
GRANULOMATOUS DISEASE TESTS:
and thyroglossal duct cysts.
o Serological test
II. INFLAMMATORY DISORDERS o Skin test
 When to perform biopsy: o Biopsy for tissue confirmation
1. Actively infetiouc condition that do not 1. Incisional biopsy – contraindicated because it
respond to conventional antibiotics could cause draining of the fistulae
2. Progressively enlarging nodes 2. Excisional biopsy – curative as well as diagnostic
Medical Therapeutics
MALIGNANT HYPERTHERMIA
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ADENOPATHY IN PATIENTS
1. Rapidly enlarging nodes
2. Tender nodes
3. Nodal enlargement with systemic symptoms

Biopsy preferably FNA


1. Tender enlarged nodes – TB/Nocardia
2. Non-tender nodes – Kaposi’s sarcoma/lymphoma

Traumatic Masses:
a. Pseudoneurysm
b. Neuroma
c. Fibroma

WHEN TO SEEK CONSULTATION FOR ENDOSCOPY


1. History and PE reveals no obvious diagnosis
2. UTZ – solid mass
3. No response to clinical trial of antibiotics
4. FNA of mass shows malignancy
5. Equivocal FNA biopsy and chronic tobacco/alcohol use

SUMMARY
1. Inflammatory masses – trial of antibiotics if there is
persistence of growth then do excision after work-up
2. Pediatric – biopsy only if:
a. Progressive growth
b. Isolated or asymmetric node
c. Supraclavicular mass
d. Adenopathy with systemic symptoms or non-nodal
lymphoid enlargement (tonsil, liver, spleen)
3. Adult – only after complete head and neck work-up
4. FNA initially:
FNA (+) for CA: endoscopy + guided biopsy excision
prepared for neck dissection.
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