ENT HEAD & NECK TUMORS 2nd Shifting/September 23, 2010

Gatongi, Ngwenya, Gitau, Lafong, Hasan, Madhu-Nagpal

Common neck masses A. Neoplastic 1. Metastatic a. Unknown primary CA b. EPidermoid Ca 2. Primary head and neck a. Epidermoid CA b. Melanoma 3. adenoCA 4. lymphoma 5. salivary CA 6. lipoma 7. angioma 8. carotid body tumor 9. rhabdomyosarcoma B. Congenital and development 1. Sebaceous cyst 2. Brachial cleft cyst 3. Thyroglossal duct cyst 4. Lymphangiopma/hemangioma 5. Dermoid cyst 6. Ectopic thyroid tissue 7. Laryngocoele 8. Pharyngeal diverticulum 9. Thymic cyst C. Inflammatory 1. Lymphadenopathy a. Bacterial b. Viral c. Graniulomatous 2. Tuberculous 3. Cat scratch 4. Sarcoidosis 5. Siladenitis 6. Congenital cysts

2. 3. 4.

If the mass is slow growing, it is more likely to be benign Associated symptoms y Change in voice, swallowing, pain etc. Personal habits y Prolonged use of tobacco, algohol Past history y Trauma, irradiation, surgery y

PHYSICAL EXAM 1. Direct and indirect visualization y All mucosal surface 2. Palpation y Palpate the oral cavity and neck 3. Sensory y Odors and bruit DIFFERENTIAL GROUPINGS y Vascular y Salivary y Nodal y Inflammatory y Congenital y Neoplastic CLINICAL THERAPEUTIC TESTING antibiotic usage y Where is inflammation suspected? y Duration should not exceed 2 weeks y Follow up exam is mandatory FNAB 1. 2. 3.

INITIAL CONSIDERATION 1. In ped patient ages 0-15 y Inflammation> congenital> neoplastic 2. In young adults 16-40 y Inflammation>neoplastic>congenital 3. In adult ages >40 y Neoplastic> inflammation>congenital HISTORY 1. Time course progression y If the mass is fast growing, it is more likely to be malignant

4.

Current standard care Use small gauge needle (20), (book: 23-25) Requires proper collection y Slide prep y Skilled cytopahologist On site review is most effective

IMAGING STUDIES 1. UTZ y Differentiates solid from cystic masses 2. Radionuclide scan y Locates mass within/outside the gland y Glandular functional info 3. Sialography 4. Plain film xrays 5. CT/MRI- neural structure y Most comprehensive single test y 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

Anterior compartment thyroid mass treatment decision 2. indistinct border 4.Medical Therapeutics MALIGNANT HYPERTHERMIA Page 2 of 4 y y y Provides information on the location of the mass whether nodal or glandular Provides info on the vascularity of the mass (with infusion) Nodal malignancy lucency. Accdg to Hayes Martin asymmetric enlargement of one or more cervical lymph nodes in an adult is almost always cancerous and is visually due to metastases from a primary lesion in the mouth or pharynx c. THYROID NEOPLASM y Anterior compartment masses y In children/young adults most common.1% benign hyperplasia 2. size. SALIVARY NEOPLASM y Consider any preauricular or angle of mandible mass until proven otherwise y Benign masses are asymptomatic y Malignant if there is/are: o Rapid growth o Nerve palsy o Skin fixation y Tests: o Scan little help in dx o Sialography helps in locating the mass 3. Differentiates carcinoma from lymphoma prevents endoscopy GUIDED BIOPSY SITES 1. Posterior cervical nodes nasopharynx 2. Differentiate cystic from solid lesions 3. Solid y Differentiate crystalline or colloid cyst by Amode pattern or aspiration (90-95% accurate) BASIC PATTERN 1. pyriform sinus . Complex pattern y Differentiate abscess or necrotic tumor clinically 2. Mild jugular nodes tongue base. Establish diagnosis in non-surgical head and neck patient 5. According to the study of Martin & Romies neck mass is the first symptom in CA in 12% of 1300 cases b. Primary neoplastic neck masses 1. with male preponderance & higher incidence of malignancy y In older age group has female preponderance and mostly benign y Lymph node metastases o 15% initial symptoms in papillary Ca o 40% of malignancies have nodes when operated y Tests: o Scan/UTZ o FNA 2. Results of 163 lymph node biopsies y 29.4 % epidermoid CA y 21. Excisional biopsy of a mass in an adult prior to a complete head and neck evaluation is contraindicated y Primaries foung on the initial examination o Memorial 218 patients 65% o MD Anderson 259 patients 52% FNA APPLICATION 1. BRACHIAL CLEFT CYST y Onset: late childhood or early adulthood and follows upper respiratory infection y Location: anterior triangle of the neck y Tests: UTZ cyst y TX: o Control initial infection o Avoid incision and drainage o Total tract incision o ULTRASONOGRAPHY PATTERN 1. Supraclavicular nodes lung. Allay patient fear of cancer aloows informed observation of hyperplastic nodes 6.4% lymphoma or hodgkins y 10. GIT. High and mild jugular nodes tonsil 3. Confirm metastases from distant known primaries 4. CAROTID BODY TUMOR y During PE o There is presence of thrill bruit o Compressible refills o Moves side to side NOT up and down y Diagnosis ARTERIOGRAM o Demonstrate a characteristic highly vascular mass at the carotid bifurcation y Found in older age groups y Elevates and moves with the skin 4. Undiagnosed neck masses in an adult are metastatic carcinoma until proven otherwise a. Cystic y Differentiate lymphoma and hyperplastic node by A-mode testing or aspiration 3. GUT SPECIFIC NECK MASSES I.

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

__________________________________ Sino ang batang ayaw tumuwad?? GOOD LUCK SA EXAMS!!! PA*TY PA*TY!!! YEAH!! . Fibroma WHEN TO SEEK CONSULTATION FOR ENDOSCOPY 1. Non-tender nodes Kaposi s sarcoma/lymphoma Traumatic Masses: a. spleen) 3. liver. Adult only after complete head and neck work-up 4. Tender nodes 3. FNA initially: FNA (+) for CA: endoscopy + guided biopsy excision prepared for neck dissection. History and PE reveals no obvious diagnosis 2.Medical Therapeutics MALIGNANT HYPERTHERMIA Page 4 of 4 ADENOPATHY IN PATIENTS 1. Equivocal FNA biopsy and chronic tobacco/alcohol use SUMMARY 1. Neuroma c. Progressive growth b. Tender enlarged nodes TB/Nocardia 2. FNA of mass shows malignancy 5. Nodal enlargement with systemic symptoms Biopsy preferably FNA 1. No response to clinical trial of antibiotics 4. UTZ solid mass 3. Adenopathy with systemic symptoms or non-nodal lymphoid enlargement (tonsil. Pediatric biopsy only if: a. Rapidly enlarging nodes 2. Pseudoneurysm b. Inflammatory masses trial of antibiotics if there is persistence of growth then do excision after work-up 2. Isolated or asymmetric node c. Supraclavicular mass d.

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