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  1. 1. EVALUATION AND MANAGEMENT OF HEAD AND NECK MASSES Jeffrey Bumpous, MD PURPOSE: The purpose of this lecture is to learn how to evaluate and treat head and neck masses. OVERVIEW: Using the case study format, the student is expected to recognize common head and neck lumps. Learn the important questions to ask in the history, what to look for in the exam, and what ancillary tests to order. Finally, the student should understand the usual treatment for each type of mass. I. LEARNING OBJECTIVES A. To know the source of head and neck lumps B. To recognize common head and neck lumps C. To understand the pathology of lymph nodes, salivary gland, and thyroid glands II. SOURCES OF HEAD AND NECK LUMPS A. Lymph nodes B. Congenital masses C. Thyroid gland D. Salivary glands III. LYMPH NODE PATHOLOGY A. General 1. 200/600 lymph nodes in the body are located in the head and neck 2. Definition of an abnormal lymph node a. Newborn--any palpable node/mass regardless of size b. Child--any lymph node > 1 cm c. Adult--any lymph node > 3 mm 3. 90% of unexplained neck masses in children are benign 4. 90% of unexplained neck masses in adults are malignant B. Cervical lymphadenitis 2. In children 90% of benign masses are lymphadenitis a. Reactive hyperplasia or Alymphadenitis@ is an immune response within a lymph node. b. Cervical adenopathy is most commonly caused by viral or bacterial lymphadenitis c. Characterized by mild local discomfort, slight fever, malaise 3. Most cervical adenitis in children is caused by Staph Aureus and Beta hemolytic Strep 4. Sources include dental caries, pharyngitis/tonsillitis, rhinitis/sinusitis 5. Treatment is beta-lactam-resistant antibiotic (Augmentin, nafcillin, cefuroxime) 6. There are numerous less common etiologic agents (Cat scratch, atypical mycobacteria, etc) C. Asymptomatic neck mass 1. In the absence of node tenderness, fever, or other URI symptoms, lymphadenopathy is probably not of infectious etiology. 194
  2. 2. 2. Adults with isolated neck masses should have a complete head and neck exam (including laryngoscopy), a fine needle aspiration is often helpful. D. Lymphoma 1. Lymphomas are primary neoplasms of lymphoreticular tissue 2. Hodgkin=s lymphoma most commonly presents with cervical adenopathy 3. One third have constitutional symptoms: fever, night sweats, weight loss 4. There is a bimodal age peak: 20-30 y/o, > 70 y/o IV. CONGENITAL NECK MASSES A. General 1. Most common non-inflammatory neck masses in children 2. Often present at birth, can appear at any age a. Lateral neck masses: branchial clefts b. Midline: thyroglossal duct, dermoid, teratoma, ranula c. Entire neck: lymphangioma, hemangioma B. Branchial Clefts 1. Branchial cleft cysts are epithelial lined cysts, sometimes with an internal or external opening, resulting from disrupted closure of branchial clefts in the embryo. 2. Branchial fistulas have an internal opening in the aerodigestive tract, and drain onto the cervical skin. 3. Present as lateral neck masses, anterior to the SCM muscle. C. First branchial clefts 1. Result from disrupted closure of the first branchial cleft, which normally forms the external auditory canal. a. Type I-duplication of the EAC b. Type II-tract from EAC, through parotid, to angle of mandible 2. Type I presents as mass anterior or posterior to ear 3. Type II presents as abscess or mass near angle of mandible 4. Surgical excision recommended for diagnosis and prevention of infectious complications D. Second branchial clefts 1. Represents > 90% of branchial cleft anomalies 2. Presents as fluctuant mass or draining fistula anterior to the SCM, often following a URI 3. Tract ends in the tonsillar fossa 4. Usually presents in children or young adults 5. Treatment is excision of the entire cyst+tract through a stair step incision E. Third branchial clefts 1. Rare cysts which present as a mass in mid or low neck, anterior to SCM 2. Tract enters pharynx or pyriform sinus (derivatives of the third branchial pouch) 3. Excision requires detailed knowledge of cranial nerve/upper neck anatomy F. Thyroglossal duct cysts 1. Develop as remnants of embryonic thyroid descent 2. Present as slowly enlarging, cystic midline neck masses, near or above hyoid bone 3. Mass elevates in the neck with tongue protrusion 4. Treatment is surgical excision (Sistrunk procedure-removal of cyst and central 195
  3. 3. hyoid with any tracts leading to the tongue base) G. Dermoid cysts 1. Midline masses that occur over the nasal dorsum, medial eye area and midline neck 2. Do not elevate with tongue protrusion 3. Contain variety of tissues from all three germ layers 4. Treatment is surgical excision H. Teratoma 1. Large, semi-cystic masses found in newborns. 2. Contain mature elements of ecto, meso, and endoderm. 3. Often cause airway (tracheal) or esophageal compression. 4. Treatment is surgical excision. I. Lymphangioma 1. Benign tumor arising from primordia of lymph vessels 2. Soft, compressible, painless mass shortly after birth 3. Multiloculated on CT, often in posterior triangle of neck 4. Treatment is surgical excision, with sparing of neural/vascular structures. J. Hemangioma 1. Most common head and neck neoplasm in children. 2. Localized, painful, rubbery swelling with smooth surface. 3. Usually cutaneous and presents in the first few months of life, grows first 12 months, then regresses 90% of time 4. Because most will regress/resolve, observation is recommended unless vital structures or functions are impaired such as vision, deglutition, breathing, etc. Systemic and intralesional steroids are also effective in some circumstances. V. SALIVARY GLAND PATHOLOGY A. General 1. The salivary glands include the major glands: parotid, submandibular, and sublingual, and the minor salivary glands which are spread throughout the upper aerodigestive tract but are concentrated on the palate, buccal mucosa, floor of mouth. 2. The salivary glands are subject to inflammatory disorders, calculi, and benign and malignant tumors just as other solid organs. B. Acute sialadenitis 1. Presents as diffuse enlargement of the involved gland, with induration and tenderness. Purulent saliva can sometimes be expressed from the duct orifice of the involved gland. 2. Occurs in parotid > submandibular gland in states of dehydration (post-op patients), or can be caused by calculi, stricture of duct, poor oral hygiene or viral infection. 3. When acute and post-op, usually caused by Staph Aureus. 4. Treatment is hydration, gland massage and IV anti-Staph antibiotics. 5. Occasionally leads to abscess requiring surgical drainage. C. Chronic sialadenitis 1. Recurrent, mildly painful postprandial enlargement of submandibular gland. 2. Pathogenesis: reduced secretion and stasis, electrolyte abnormality or stone. 3. Treatment: sialagogues, massage, hydration, antibiotics. 196
  4. 4. D. Sialothiasis 1. Calculi present as acute, often severe postprandial pain and swelling. 2. 80% involve the submandibular gland, and 20% the parotid gland. 3. Predominantly calcium phosphate stones, single in 75%. 4. Many (80% submandibular calculi) are radiopaque and can be seen on a dental occlusal x-ray, or simply palpated in the floor of mouth along Wharton=s duct. 5. Usually lead to chronic sialadenitis from ductal ectasia or stricture. 6. Stone can be removed under local from floor of mouth if palpable. E. Salivary gland tumors 1. Breakdown on frequency of salivary gland tumors: Parotid gland 80% of tumors 25% are malignant Submandibular 10-15% 50% Sublingual < 5% 75% Minor glands < 5% 75% 2. Note the larger the salivary gland, the more likely a lump is a benign tumor. Conversely, tumors arising in the sublingual or minor glands are very likely malignant. 3. Benign tumors present as slow growing, painless masses and have no known etiologic agent. 4. 65% of all salivary gland masses are pleomorphic adenomas (also known as benign mixed tumors). Warthin=s tumor is next most common benign tumor (6-10%). F. Salivary gland malignancy 1. Malignant lumps are usually more rapidly growing, sometimes painful, or can cause facial nerve paralysis when in the parotid. 2. Diagnostic work up of solitary lump is exam only, although FNA + CT scan is often performed for deep lobe lesions. FNA has fairly low diagnostic accuracy. 3. Mucoepidermoid carcinoma is most common malignancy, making up 6-9% of salivary neoplasms. 4. Adenoid cystic carcinoma is second most common in all glands, and most common submandibular and minor gland malignancy. 5. Treatment for malignancy is total gland removal and XRT for Ahigh grade@ neoplasms VI. THYROID GLAND PATHOLOGY A. General 1. Thyroid nodules are very common: they are clinically apparent in 4-10% of the population, and autopsy studies show > 50% of people > 50 years of age have a nodule. 2. However, the incidence of cancer in a nodule is only 5-20%. 3. Physicians have a challenging task in identifying those nodules which are at risk for being malignant. B. Thyroid nodules 1. History of prior head/neck radiation, familial syndromes (MEN) or simply family history of Aneck operations,@ or family history of thyroid disease is important. 2. Rate of nodule growth, its firmness or character are important, as well as Hx of hoarseness, dysphagia. 197
  5. 5. 3. Exam: must characterize entire gland as well as nodule, check for cervical lymphadenopathy, and examine the vocal cords for evidence of paralysis. 4. Lab work: thyroid profile (TSH, T4/T3, RT3U), calcium, calcitonin can be considered. 5. Elevated T4 with low TSH suggests functioning adenoma. 6. Radionuclide scans such as Technetium can identify Acold@ or nonfunctional areas, which have a higher incidence of malignancy (about 20% of cold nodules). These scans can also help diagnose MNG and Hashimoto=s (see below). 7. Ultrasound is valuable to characterize a mass as cystic and can help one follow a cystic mass after aspiration to rule out recurrence. Purely cystic nodules are rarely malignant, although thyroid carcinomas can have a cystic component. 8. Thyroid hormone Areplacement therapy@ can be diagnostic in that malignant nodules usually don=t regress with suppression therapy. 9. Fine needle aspiration is often the first diagnostic step and is good for diagnosing Papillary CA, but follicular cancers require identification of capsular invasion and thus are rarely called on FNA. C. Thyroid Cancer 1. Four types, in decreasing order of frequency and prognosis are: papillary, follicular, medullary and anaplastic. 2. Papillary and follicular carcinomas are referred to as Awell differentiated,@ and with proper treatment have excellent long term prognosis. 3. Medullary CA heralded by high calcitonin levels, MEN syndromes. 4. Anaplastic CA nearly always fatal within months, airway control is needed, and is rarely resectable. 5. The treatment for well differentiated thyroid Ca is variable between institutions, but the options are thyroid lobectomy, subtotal thyroidectomy, total thyroidectomy. 6. Postoperative I-131 is used in a diagnostic and therapeutic manner in many cases. D. Hashimoto=s thyroiditis 1. Presents as diffusely enlarged, rubbery, painless thyroid gland. 2. Autoimmune etiology, anti-thyroglobulin and anti-microsomal antibodies are detectable. 3. Technetium scan characterized by Asalt and pepper@ uptake, and FNA reveals lymphocytic infiltrate. 4. Treatment is thyroid suppression (thyroxin) and not anti-thyroid meds (used in hyperthyroid states). E. Multinodular goiter 1. Thyroid often diffusely enlarged with multiple nodules. 2. Technetium scan shows hypofunctional areas, but this alone is not sensitive or specific enough to rule out a malignancy. 3. FNA can help with diagnosis (benign cellularity with colloid). 4. Surgical removal only for airway compression, dysphagia, or cosmetic appearance. VII. WHEN TO REFER A. Deep neck abscess suspected on history/exam or CT scan. Surgical drainage is indicated. 198
  6. 6. B. Children and young adults with multiple, bilateral, or supraclavicular masses may need open biopsy to rule out lymphoma. Adults with neck masses that persist for more than 3 or 4 weeks require otolaryngologic referral. C. Excision of the gland is indicated for frequent, painful enlarged, firm single gland compared to others, or suspected or x-ray film-proven stone. D. Excisional biopsy is indicated for all salivary gland masses. A superficial parotidectomy or submandibular gland excision is the minimal procedure for diagnosis in most instances. E. It is difficult to generalize, but most surgeons would agree on the following: 1. Single cold nodule 2. FNA revealing microfollicular features or atypical cells in a nodule 3. Nodule which enlarges despite suppression therapy 4. Nodule in patient with history of radiation exposure 5. Rapidly growing or firm nodule 6. Nodule in patient with family history of medullary cancer of thyroid 7. Nodule and cervical mass VIII. PITFALLS A. A patient with significant swelling in the lateral/upper neck accompanied by high fever and usually high WBC not responding to oral antibiotics may have a deep neck abscess. Deep neck abscesses are not fluctuant on exam because of their location deep to the SCM muscle. B. An incomplete exam of the oral cavity, pharynx, and larynx often leads to delayed diagnosis of carcinoma of the tongue, oral cavity, or pharynx/larynx in the patient with a neck mass that ultimately is proven to be metastatic. C. Systemic disorders such as Sjogrens, Sarcoidosis, or other collagen vascular disorders may lead to or present with chronic sialadenitis. D. A patient with ABell=s palsy@ should have an exam of the ear/tympanic membrane and the face/parotid to rule out malignant or infectious etiologies of facial nerve paralysis. Remember the course of cranial nerve VII. E. A CT scan or MRI is not necessary in most cases of the work up of thyroid nodules. In fact, iodinated contrast given for a CT scan will preclude some thyroid imaging studies that rely on uptake of substances. IX. SUGGESTED READING Wrightson WR. Head and neck. In: Wrightson WR, ed. Pocket Surgery. Malden, MA: Blackwell Science 2002:91-98. Bumpus JM. Head and neck cancers. In: Galandiuk S, Carter MB, Abby M, eds. When to refer to a surgeon. St. Louis: Quality Medical Publishing 2001:37-44. Polk HC Jr, Gardner B, Stone HH, eds. Basic Surgery; 5th ed. St. Louis: Quality Medical Publishing, 1995 199