What Every Surgeon Should Know

About Head and Neck Surgery

David P Goldstein MD FRCSC
Otolaryngology-Head & Neck Surgery
Surgical Oncology
University Health Network
David.goldstein@uhn.on.ca
Objectives
Focus on approach to evaluation and management
of a neck mass and Parotid masses

Briefly highlight key issues in diagnosis &
management of following types of neck mass
Congenital disorders
thyroglossal duct and branchial cleft cyst
Salivary gland masses
Carotid body tumor
Squamous cell carcinoma


Differential Diagnosis
Congenital
Thyroglossal duct cyst
Branchial cleft cyst
Lymphangioma

Inflammatory
Infectious
Non-infectious

Neoplastic
Primary malignancies
Metastases to nodes

Approach to the Differential
Diagnosis of Neck Masses
Age
Location, Location, Location
Duration of symptoms
Risk factors
Contents of neck mass
Differential Diagnosis
Age is a major determinant
< 20 years C I N
20 40 years - I C N
> 40 years - N I C
C= congenital
I= inflammatory
N= neoplastic
Location
Anterior Triangle
Anterior- midline
Posterior- SCM
Inferior- clavicle
Superior- mandible

Posterior Triangle
Anterior- post border of
SCM
Posterior- trapezius
Superior- junction of SCM
& trapezius
Inferior- clavicle
Midline
Congenital
Thyroglossal duct cyst
Dermoid

Lateral Neck/Ant
Congenital
Branchial cleft cyst
Thymic cyst

Posterior Neck
vascular/Lymphatic
malformation


Beware of the cystic neck mass
in an adult
Differential of Congenital Neck Masses
Based on Location
Differential Diagnosis of Neoplastic Neck
Masses based on Location
Lateral Anterior
Benign
Schwanomas
CBTs
Salivary gland

Malignancies
Lymphoma
Nodal metastasis
UADT
Skin
Salivary gland

Midline Anterior
Thyroid
Larynx cancer
Direct extension
Metastasis

Posterior
Benign
Schwanomas
Malignant
Lymphoma
Nodal metastasis
Skin
UADT
Non H & N
Supraclavicular nodes (virchow nodes)
- Classically represents nodal metastases from below the diaphragm
Differential Based on Growth Rate
Slow growing over years
Tend to be benign or low grade malignancy

Rapidly growing neck masses
Infectious
Malignant tend to progress over period of
weeks to a few months

Cystic Neck Mass
Congenital
Thyroglossal duct cyst
Branchial cleft cyst

Squamous cell cancer
Oropharyngeal/ tonsil primary

Thyroid Cancer
WDTC present with cystic mass
Classically has dark brown appearance

Tail of parotid masses
Warthins tumor
Necrotic Neck Mass
Infectious
Abscess
Tuberculosis

Malignant
Squamous cell carcinoma
Work-Up of a Neck Mass
History
Physical
Inspection
Palpation
Endoscopy
Diagnostic Imaging
US
CT
MRI
PET
Biopsy
FNA
Other
Intraoperative endoscopy
TB test
History
Duration & growth rate of the
mass
Malignant lesions tend to have
progressive growth at more
rapid rate than benign disease

Location
Anterior, posterior or midline

Symptoms of inflammation or
infection
Malignant neck masses with
necrosis and skin
involvement may mimic
invasion
Associated symptoms
Dysphagia, odynophagia,
otalgia, hoarseness, oral
cavity pain, nasal obstruction,
epistaxis
Suggests UADT malignancy
B symptoms fever, weight
loss & night sweats

Risk factors
Malignancy
TB exposure
Cat scratch

Keep the differential diagnosis in mind
History
Past medical history
Skin cancer
UADT malignancy
Sarcoidosis
Fungal infection
Dental caries/dental
work
Trauma to head and
neck
Family history
Thyroid cancer
Paragangliomas

History- Risk Factors for Malignancy
Tobacco
Cigarettes, chew, betel nut, cigar

Alcohol
Two together are synergistic

Viruses
HPV- oropharynx cancer
EBV- nasopharynx cancers
HIV- kaposis sarcoma, lymphoma

Immunosupression
Transplant patients- Skin cancers, head and neck cancer

Occupational
Wood working, leather work paranasal sinus cancer
Risk Factors Contd
Previous head and neck cancer
Develop second cancer in 18% of patients

Radiation exposure
Salivary gland cancers, thyroid cancer, head and neck sarcomas

Autoimmune disorders
Sjogrens syndrome
lymphoma of salivary glands
Hashimotos thyroiditis
thyroid lymphoma

Physical Examination
Neck mass
Location
Size
Firmness
Fixation
Pulsatile
Presence of other neck masses or enlarged nodes
Movement with tongue protrusion
Auscultate for bruits if pulsatile
Investigations
If diagnosis of infectious or inflammatory is probable no
further work up is necessary and appropriate therapy
instituted

Suspected inflammatory disorders may require serologic
tests

If there is any uncertainty in diagnosis or the suspected
diagnosis is congenital or neoplastic further
investigations are required

When in doubt on your exam do further investigations
Fine Needle Aspiration
Diagnostic accuracy 70% to 90%
Simple/ cost effective
US guidance increases yield & accuracy
Indication almost any neck mass
Only relative contraindication to FNA is pulsatile neck mass
MOST IMPORTANT TEST- WHEN IN
DOUBT PERFORM
Fine Needle Aspiration
Diagnose most head and neck cancers

Suspect lymphoma
Send for flow cytometry

Cystic neck mass
Send washings
Stain for thyroglobulin

Still a role for FNA in infectious and inflammatory
disorders
C & S
Presence of pus does not necessarily exclude malignancy
Squamous cell carcinoma can present with necrotic nodes

Open Biopsy
Almost NO role in the initial work-up of a neck mass

Contraindications
Pulsatile masses
Parotid masses
Suspected malignancies and FNA not been attempted

When to do
Only after work-up is completed including FNA and diagnosis is
still in question
FNA is non-diagnostic
FNA is negative but not in keeping with clinical picture


Open Biopsy
Situations in which may be indicated
Lymphoma
FNA is suspicious for lymphoma & further tissue
needed
Cystic neck mass
FNA often inconclusive
Send cyst fluid for cytology
Do full work-up prior to open biopsy
Imaging and panendoscopy of UADT


Open Biopsy

Incisional vs excisional biopsy
Depends upon size, location and involvement if
surrounding structures and suspected pathology

Keep in mind future surgery/neck dissection
Make the incision in line with potential incision one
would use if further neck surgery is required
Diagnostic Imaging
Plain films
Limited role
CXR

Ultrasound/Doppler
Useful noninvasive test
Vascularity
Solid vs Cystic
Sensitive for adenopathy
Guided FNA
CT scan & MRI
Location
Relation to other structures
Vascularity
Bone invasion
MRI for soft tissue
Tongue
No dental artifact
MRA/MRV

MRI
Soft tissue
No dental artifact
oral & oropharynx
Bone invasion
CT scans
Bone imaging
Soft tissue imaging
Dental artifact
The Pulsating Neck Mass
Differential Diagnosis
Non-vascular mass situated near carotid artery
Carotid body tumor (paraganglioma)
Carotid artery aneurysm

Work-up
Image first
CT with contrast or MRI
If confirmed vascular mass get MRI (MRA & MRV)
Avoid FNA but not end of world
Incisional biopsy contraindicated

Presentation & Management
of Specific Diagnosis
Thyroglossal Duct Cyst
Presentation
May occur at any age but
most common in first 2
decades of life
Midline at level of hyoid to
thyroid, may be off centre
May have hx of infection
Classic sign is rising with
tongue extrusion

Diagnosis
History & Physical
Imaging

Thyroglossal Duct Cyst
Cautions
May have papillary ca arising in thyroglossal duct cyst
rare but I perform FNA
Cystic nodal metastasis from papillary thyroid ca to
delphian node may have similar presentation

Treatment
Excision sistrunk procedure (remove cyst with track
up to tongue base including central portion of hyoid
bone)
Cosmetic and prevent recurrent infection


Branchial Cleft Cyst
Presentation
mass along the anterior border
of the SCM +/- a sinus tract
Smooth painless slow growing
unless infected, may fluctuate
in size
Treatment
Surgical excision with removal
of the tract
Nerves at risk CN IX, X, XI
XII

Lymphoma
hx of lymphadenopathy non-resolving
B symptoms fever, night sweats, weight loss
nodes soft mobile and rubbery, may be very large bull neck
Diagnosis
FNA- special solution & adequate amount
Open biopsy- after FNA & lymphoma suspicious clinically
must be sent fresh
immunophenotyping & flow cytometry
Carotid Body Tumor
Carotid body tumors
(Paraganglioma)
Arise from carotid body located at
bifurcation between ICA & ECA
Familial in up to 30%
Bilateral or multiple


Diagnosis
Classic imaging characteristics
Vascular mass splaying ICA
and ECA lyres sign
MRI get salt & pepper pattern
from the flow voids

Carotid Body Tumor
Treatment
Excision
Proximal and distal control of CA
Prepared to bypass

Complications
Vascular injury
Stroke
CN injury CN IX,X,XII


Squamous Cell Carcinoma
FNA Dx of SCC
Primary detected No Primary identified; Aka unknown primary
Stage tumor
Treat primary tumor
Treat neck
Imaging to stage the neck disease and help
identify the primary source
Panendoscopy in OR with biopsies of tongue
base, hypopharynx, nasopharynx and
unilateral tonsillectomy
Treat neck and potential primary
sites with radiation
Squamous cell carcinoma
General Management Principles
Staging
Hx, Px (flex scope)

Imaging
CT Head and neck
MR for tongue/tongue base
Chest CT r/o synchronous primary

Panedoscopy/Quadroscopy (EUA under GA)
Esophagoscopy, Bronchoscopy, Laryngoscopy, +/- nasopharynx
Used for cancers of larynx, hypopharynx and +/- oropharynx
Assess the extent of the tumor & surgical resectabilty
Obtain biopsy specimens
Assess for 2
nd
primary

Squamous cell carcinoma
General Management Principles
Treatment Options
Surgery
Radiation
Chemotherapy
Combination of both
Rads or chemo can be given pre- or post op

Treat the primary site and the cervical lymph
nodes
Try and treat cervical lymph nodes with the same
modality of therapy used for the primary site
How do we decide which treatment
to offer
Provide the treatment that will offer the highest
survival & control rate
based on literature
Early stage disease often similar
Advanced disease usually combination
QOL and morbidity
Organ preservation (larynx, hypopharynx)
Preserve form and function (oropharynx
Swallowing, speech, cosmesis
Goals of Treatment
Cure
Local regional control
Survival

Palliation
Pain
Bleeding
Cosmesis

Squamous cell carcinoma
General Management Principles
Oral cavity surgery
Oropharynx (tonsil, tongue base)- radiation or
chemoradiation
Hypopharynx cancer radiation or
chemoradiation
Larynx- transoral laser surgery for small tumors,
radiation or chemoradiation for most
Nasopharynx- chemoradiation or radiation

Adenocarcinoma
FNA diagnosis of adenocarcinoma in the neck
from a distant site
Lung, breast, GI, GU
May require an open biopsy to get more tissue
for analysis to help identify site
Image chest, abdo, pelvis
Rarely treat the neck b/c metastatic disease -
palliative therapy to prevent obstruction of
trachea or esophagus
Neck dissection - Only if primary site is controlled and
patient is potentially curable
Salivary Gland Masses
Major Salivary Glands
Parotid- 80%
(80%benign:20%malignant)
Submandibular 15% (50:50)
Sublingual (40:60)


Minor Salivary Glands
Oral cavity/ oropharynx
Larynx
Nose & paranasal sinuses
Classification
Non-Neoplastic
Congenital
Granulomatous
Infectious
Non-infectious
Inflammatory
Hemangiomas
Vascular
malformations
Lymphatic
malformations
1
st
Branchial
cleft cyst
Classification
Non-Neoplastic
Congenital
Granulomatous
Infectious
Non-infectious
Inflammatory
HIV
TB
Atypical TB
Actinomycosis
Cat-Scratch
Toxoplasmosis
Tularemia
Fungal

History & Physical Exam
Majority of neoplasms (benign or malignant)
present as asymptomatic swelling

Risk factors for malignancy
Majority idiopathic
Ionizing radiation
Sjogrens syndrome
Lymphoma
Skin cancers



Clinical Presentation of Cancers
Pain
Fixation & invasion of surrounding
structures i.e. dermis, mandible
Trismus
Facial nerve paralysis
Adenopathy

Facial Nerve Paralysis with a
Parotid Mass
Very rarely occurs with benign tumors
12% to 15% parotid malignancies will
exhibit facial paralysis
Pathologies
Adenoid cystic carcinoma
Poorly differentiated carcinoma
SCC
Lab Tests
Serology if suspect auto-immune
process

Biopsy
FNA mainstay
Open biopsy
Very rarely indicated for parotid masses: AVOID in
most cases
Fine Needle Aspiration

Debate about utility of FNA in parotid masses

Among all H & N sites the parotid gland is associated
with the highest FNA inaccuracy rates

False negative rates higher then false positive
Sensitivity rates reported can be as low as 38% when comes
to recognizing malignant nature of parotid masses

Diagnostic precision is difficult

Determine high vs. low grade tumors is also difficult
Why do an FNA?
Accuracy in determining benign from malignant
disease
Rates of ~ 90%

It may help in planning surgery especially informed
consent

It may help in timing of surgery in resource
restricted climate

Change clinical approach in up to 30% of patients

Results interpreted in the face of the clinical
presentation and imaging

Diagnostic Imaging
Ultrasound
Identifying a mass
Guide FNA
Assessing adenopathy

Technitium-99m Scan
Diagnosis of Oncocytoma or
Warthins tumor

Sialography
Rarely used
Little role in routine work-up of
a parotid mass

CT Scan and/or MRI
Main modalities for
imaging parotid
neoplasms
Value of Imaging
Know what you are getting into
tip of iceberg with deep lobe involvement
Approach


Malignancy
Resectability
Skull base
Structures requiring resection
Nodal status
Facial nerve status
Adenoid cystic carcinoma- proximal portion
Common Pathologies
Benign
Pleomorphic adenoma
Malignant degeneration into carcinoma ex-pleomorphic
adenoma in 2-10% of pleomorphic adenomas
Warthins tumor
10% bilateral
Malignant
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Metastases from skin cancers
Prognostic Factors with Malignancy
Histology
High Grade Malignancies
Older Age
Pain at presentation
Stage of primary tumor & nodal metastases
Skin invasion
Facial nerve dysfunction
Peri-neural growth
Positive margins
Malignant Secondary
Neoplasms
Direct extension
Cutaneous SCC/BCC

Lymphatic metastases
SCC
Melanoma

Hematogenous
Metastases
Lung, Kidney, Breast

Direct extension
Metastatic SCC
Factors in Decision Making
Patient factors
Age
Co-morbidities
Patients concerns

Tumor Factors
Histology
Benign vs malignant
Do you have a diagnosis & how certain are we
Growth rate
Risk factors for malignancy
Surgery
Majority can be managed with a superficial
parotidectomy
Subtotal parotidectomy
Involvement of deep lobe
Parotidectomy and transcervical approach to
parapharyngeal space tumours
Surgical Complications
Temporary VII nerve paresis=21%
Freys syndrome=6%
Infection=3.6%
Hematoma=2.7%
Hypertrophic scar=2.4%
Seroma=0.8%
Salivary fistula=0.4%
Indications for Post-operative
Radiotherapy
High grade cancers
Recurrent cancers
Gross or microscopic residual disease
Regional lymph node metastases
Evidence of locally advanced tumors
Thyroid Cancer
Epidemic of Thyroid Cancer
3.6 per 100 000 in 1973 8.7 per 100 000 in 2002
represents 2.4 fold increase
Davies, L. et al. JAMA 2006;295:2164-2167.
Thyroid Malignancies
Well-Differentiated Carcinomas (80-85%)
Papillary Thyroid Carcinoma (PTC)
Follicular Thyroid Carcinoma (FTC)
Medullary Thyroid Carcinoma (5-10%)
Anaplastic Thyroid Carcinoma (5-10%)
Other malignancies
Lymphomas
Distant Metastases

Well-Differentiated
Thyroid Carcinoma
Papillary Thyroid CA
75-80% of thyroid
carcinomas
Frequently Multifocal
Dx on FNA or FS
Common Nodal Dz
Infrequent Distant Dz
Slightly Better Prognosis
Follicular Thyroid CA
5-10% of all thyroid
carcinomas
more aggressive natural
history
Solitary Lesion
Dx on final path
Infrequent Nodal Dz
Common Distant Dz
Slightly Worse Prognosis
Medullary Thyroid Carcinoma
C - cell/parafollicular cell origin
May be sporadic/nonfamilial (80%) or familial (20%)
Familial forms
Medullary thyroid carcinoma alone
MEN 2A (Sipples)
MTC, Pheochromcytoma, Hyperparathyroidism
MEN 2B
MTC, Pheochromocytoma, Mucosal Neuromas,
Mutations on chromosome 10 for the RET proto-
oncogene
Regional lymph node metastases - 50%
Distant metastases

Medullary Thyroid
Carcinoma
Diagnosis / Screening
Pentagastrin Stimulation with measurement of
calcitonin levels
Ret proto-oncogene screening
Patients who screen positive should undergo early
thyroidectomy
Early intervention has resulted in 85% DFS at 15-20
years
Serum calcitonin levels are used as a tumor marker
in follow-up
Medullary Thyroid
Carcinoma
Treatment
exclude pheochromocytoma
total thyroidectomy
central compartment lymphadenectomy
elective lateral neck dissection for patients with
palpable thyroid disease
therapeutic lateral neck dissection for patients
with palpable neck disease
Treatment
Adjuvant external beam radiation may be used to
enhance locoregional control
The role of chemotherapy remains to be defined


Anaplastic Carcinoma
Rare tumor noted for its rapid growth and
nearly uniform lethal nature
Typically develops in a pre-existing well
differentiated thyroid carcinoma or a
goiter
Poor prognostic factors
Advanced age
Presence of regional or distant metastases
Lymphoma of Thyroid Gland
Thyroid Nodules
Approximately 95% of thyroid nodules are
benign
4-7% of adults have thyroid nodules
Women > men
Likelihood of malignancy=5%
Malignancy in clinically apparent
nodules=20%


Work-up of Thyroid Nodule
History
exposure to ionizing radiation
family history of thyroid carcinoma or other endocrine
neoplasms (MEN syndromes)

Physical examination
Vocal cord paralysis
Fixed and firm
Cervical nodes

Investigations
FNA
Thyroid U/S
TSH

No role for calcitonin, thyroglobulin and
thyroid scintigraphy in the initial work-up
FNA (R-A)
Repeatedly
Nondiagnostic (R-A)
Cystic
nodule
Solid
nodule
Observation
or surgery
Surgery
strongly
considered
Suspicious for
papillary ca or
Hurthle cell
neoplasm
Surgery
(R- A)
Indeterminate Cytology
(suspicious, follicular
lesion or neoplasm)
Follicular
lesion
Benign
Follow
(R-A)
Thyroid
scan
Hot Cold
(R-B)
FNA
Risk-group Definitions
AGES
A age (> 40)
G grade
E extent of tumor
extrathyroidal invasion
distant metastases
S size


Other TNM & MACIS
AMES
A age(M>40,F>50)
M metastases
(distant)
E extent of tumor
S size


Patterns of Failure by Risk Groups
Differentiated Thyroid Cancer
5
10
18
10
14
17
2
12
34
Low Intermediate High
0
5
10
15
20
25
30
35
40
Local %
Regional %
Distant %
% of pts
13%
26%
50%
Overall %
Treatment
Surgery
Post-operative radioactive iodine
Post-operative thyroid suppression
External beam radiation
Post-operative screening

Total vs Less than Total
Thyroidectomy
Eliminates all cancer and
potential cancer (up to
50% CL)
Allows RAI
Allows monitoring with
thyroglobulin
Deals with tall cell and
insular Ca & prevents
transformation of PTC to
anaplastic ca
No compelling
evidence for survival
advantage
Difficult for RAI
Thyroglobulin not
possible
Spares the
parathyroids & RLN


Hemi vs Total Thyroidectomy
Low risk disease
Controversial
R.R decreased with total thyroidectomy
Some studies shown no difference

High risk patients
Local & regional RR lower in total thyroidectomy
Possibly improved cause specific survival

Complications of Thyroidetcomy
Hypoparathyroidism
Temp vs Permanent

Recurrent Laryngeal Nerve Injury
Unilat vs bilat
Temp vs Perm
Complications
Post-operative hematoma
Concern re: airway
Prevent obstruction with incomplete strap
muscle reapprox inferiorly
Drains do not prevent
Management
Airway emergency
Open at bedside if patient in resp distress
To OR

Neck Management
Clinically negative neck no neck dissection
Nodal metastases at presentation
Do not adversely affect survival
Does increase risk of locoregional recurrence
80% of nodal metastases are central compartment
Lateral ND only if clinically positive nodes or identified
intra-op
Functional neck dissection level II-V
Spare IJV, SCM, CN XI, cervical plexus
Radioactive Iodine
Agent - I
131
Effect

Goal of therapy
Scan
Thyroid ablation
Therapeutic
Complications
Short term
Long term
Radioactive Iodine
Only useful in cases of well differentiated
thyroid malignancies
Results
Overall efficacy difficult to clearly delineate
Studies have shown decreased locoregional
recurrences and increased survival in some series
Less efficacious in unresectable disease
Pulmonary metastases respond better than bony
metastases



Thyroid Nodules in Pregnancy
Uncertainty if nodules in pregnancy are more likely to be malignant
than those found in non-pregnant women
No population based studies

Recommendations (C)
FNA unless low TSH
Malignancy- follow with U/S
Significant growth by 24 wks gestation
surgery can be performed at that time point
Remains stable or diagnosed in 2
nd
half of pregnancy
surgery may be performed after delivery
Low TSH
if persists after 1
st
trimester
thyroid scan after pregnancy