Approach to Neck Masses & Thyroid Nodule

By: Amir Reza Honarmand (Chief Stager of Surgery ) Shariati Hospital Tehran

Differential Diagnosis
• Congenital/Developmental • Acquired Inflammatory/Infectious Neoplastic – Benign or Malignant primary or secondary Vascular – AVM, ectatic vessels, aneurysms Traumatic – Hematoma

Congenital Developmental • Midline Thyroglossal duct cyst Dermoid • Lateral Brachial cleft cyst – FNA showing debris, cholesterol clefts / may present with acute infection Normal anatomy – C1, hyoid, etc. Muscular – torticollis

Inflammatory Lesions
• Infectious Bacterial – strep/staph, cat scratch (bartonella), TB Fungal – actinomycosis Viral (HIV, EBV, mumps) Parasitic – toxoplasmosis • Inflammatory Granulomatous disease – sarcoid Reactive

Tumor of Neurogenic Origin

• Neurofibroma • Schwannoma • Paraganglioma (carotid body tumor)

Metastatic Cervical Nodes
• Head and Neck Primary (upper aerodigestive tract) • Remote Primary (Virchow’s node) esophagus, lung, breast, stomach, renal cell carcinoma • Malignant Melanoma • Skin Cancer • Unknown Primary

Incidence of Pathologic Lesions in Neck Masses in Adults
• Primary thyroid disease 50% benign, malignant and metastatic • Metastatic cervical adenopathy 35% epithelial, other • Congential 12% • Inflammatory 3%

• Normal nodes <1 cm-1.5 cm • Inflammatory nodes usually resolve within 2 wks • First Rule: Any neck mass in an adult patient must be approached as being neoplastic and possibly malignant • Second Rule: Immediate removal of enlarged lymph node for diagnostic purposes is a disservice to the patient with metastatic cervical carcinoma • Third Rule: Any incision in neck can compromise future surgery

Terminology of Lymph Node Groups
Level I submental, submandibular Level II upper jugular Level III middle jugular Level IV lower jugular Level V posterior jugular Level VI paratracheal, perithyroidal

Drainage Patterns and Neck Levels
• Level I (Submandibular / Submental) drain lip, oral cavity and submandibular gland • Level II (Upper jugular) drain nasopharynx, oropharynx, parotid, and supraglottic larynx • Level III (Mid jugular) drain oropharynx, hypopharynx, and supraglottic larynx

Drainage Patterns and Neck Levels
• Level IV (Lower jugular) drain subglottic larynx, hypopharynx, esophagus, and thyroid • Level V (Posterior triangle) drain nasopharynx and oropharynx • Level VI (Paratracheal) drain thyroid and larynx

Clinical Evaluation of Neck Mass – History
• age (kids 80% benign, adults over 40 80% malignant), duration, growth, fluctuation, tenderness, B symptoms, oral/nasal/ear, skin, voice change, cough, weight loss, SOB, dysphagia • Smoking Hx, Personal Ca History, Previous irradiation, Family Ca Hx

Fine Needle Aspiration of Neck Masses
• Sensitivity of 85 – 97% for tumours • Specificity of 88 – 98% • Non diagnostic – 8 – 16% • Useful even for salivary lesions to rule out non-salivary pathology

FNA Results
• Inadequate – repeat – ?US guided • Lymphoid – “cannot rule out lymphoma” • SCC – search for primary – flexible nasopharyngoscopy • Adenocarcinoma • Melanoma • Other – small cell, poorly differentiated ca • Necrotic – this is suspicious for SCC

Laboratory Investigations
• Base on suspicion from Hx and Px • CBC, LDH • PPD • CXR for lower neck mass or lymphoma • Serology (toxoplasma, cat scratch, EBV) • US – node character – lucency, shape, hilar fat • Other imaging function of FNA result, eg CT with SCC, or MRI if unlocalized primary

Treatment of Metastatic Squamous Cervical Cancer of Unknown Primary
• Indication for primary radiotherapy • Radical neck dissection may be indicated when open biopsy proven metastatic squamous carcinoma