EVALUATION OF THE NECK Frederick Mars Untalan MD
Lymphoma More common in children  and young adults Up to 80% of children with  Hodgkin’s have a neck  mass Signs and sy...
Lymphoma FNAB – first line diagnostic test If suggestive of lymphoma – open biopsy Full workup – CT scans of chest, abd...
Salivary Gland Tumors Enlarging mass  anterior/inferior to ear  or at the mandible  angle is suspect Benign   Asymptoma...
Salivary Gland Tumors Diagnostic tests   Open excisional biopsy (submandibulectomy or    parotidectomy) preferred   FNA...
Carotid Body Tumor Rare in children Pulsatile, compressible mass Mobile medial/lateral not  superior/inferior Clinical...
Carotid paragangliomas
Carotid paragangliomas Treatment   Surgery     Mortality 8%, >5cm tumors had more      complications     Preop workup ...
Vagal paragangliomas Most commonly at nodose ganglion Painless mass at angle of mandible present  for many years – enlar...
Vagal paragangliomas
Lipoma Soft, ill-defined  mass Usually >35 years  of age Asymptomatic Clinical diagnosis  – confirmed by  excision
Neurogenic Tumors Arise from neural crest derivatives Include schwannoma, neurofibroma, and  malignant peripheral nerve ...
Schwannoma Sporadic cases mostly 25 to 45% in neck when  extracranial Most commonly between 20 and  50 years Usually m...
Congenital & Developmental Mass  Epidermal and sebaceous cysts  Branchial cleft cysts  Thyroglossal duct cyst  Vascula...
Epidermal and Sebaceous Cysts Most common  congenital/developme  ntal mass Older age groups Clinical diagnosis   Eleva...
Branchial Cleft Cyst 2nd cleft most common  (95%) – tract medial to  cnXII between internal  and external carotids 1st c...
Branchial Cleft Cyst  Most common as smooth,   fluctuant mass underlying   the SCM  Skin erythema and   tenderness if in...
Thyroglossal Duct    Cyst Most common congenital neck    mass (70%)   50% present before age 20   Midline (75%) or near...
Thyroglossal Duct Cyst Most common congenital midline mass Ectopic thyroid tissue vs. thyroglossal duct cyst Asymptomat...
Vascular Tumors Lymphangiomas and hemangiomas Usually within 1st year of life Hemangiomas often resolve spontaneously ...
Vascular Birthmarks Classification system   Hemangioma vs. malformation   Based on clinical, cellular, biologic factors...
VascularBirthmarks
Hemangiomas Most common  tumor of infancy  (10%) Slight female  predominance 60% arise in head  and neck – cosmetic  co...
Hemangiomas Clinical presentation  for diagnosis   Not seen at birth   Precursor lesion   Proliferative phase   Invol...
Complications from Hemangiomas Occur in 20%   Ulceration   Compression of vital structures   High-output cardiac failu...
Laryngeal Hemangiomas Usually in the  subglottis Healthy infant with  biphasic stridor  (croup) Behave similarly 50% w...
Treatment of Hemangiomas Why and when to treat?   Normal skin in 50%    that involute within 5    years   Other 50%-- 8...
Treatment of Hemangiomas Observation   Serial photography important to document    involution   Regular visits with rea...
Treatment of Hemangiomas  Systemic steroids    Careful selection criteria    Prednisone 2-4mg/kg for up to 6 weeks    ...
Treatment of Hemangiomas Intralesional  steroids   Usually for    vision    threatening    lesions   Combination    of ...
Treatment for Hemangiomas Surgery   Eyelid lesions, bulky    lesions, vermillion    border, nasal tip,    eyebrow   CO2...
Vascular malformations Capillary, venous, arterial, lymphatic, mixed By definition– present at birth No proliferative o...
Capillary malformations  Older term– “port-   wine stain”    Usually in     trigeminal     distribution    Most isolate...
Treatment of CapillaryMalformations Cosmetic concealing  makeup Tattooing Surgical excision  (tissue expanders) Pulse ...
Venous Malformations  Diagnosis is clinical – palpation  Treatment dependent on location (surgery   and sclerotherapy)
Vascular Tumors(lymphangioma) Older terms–  “cystic hygroma”,  “lymphangioma” Can expand with  URI Surgical  treatment ...
Arteriovenous malformations Usually clinically apparent Embolization and surgical resection
Nasopharyngeal Angiofibroma Most common benign tumor of nasopharynx Older term– “juvenile nasopharyngeal  angiofibroma”,...
Nasopharyngeal Angiofibroma Diagnosis is made by  clinical and  radiographic findings CT/MRI Biopsy- rarely  indicated...
Nasopharyngeal Angiofibroma Angiography      Histology
Nasopharyngeal Angiofibroma Treatment   Embolization and surgery     Autologous blood/Cell Saver     Approaches      ...
Malignant Vascular Tumors Angiosarcoma   Extremely rare (50% in    head and neck)   Prognosis on tumor size,    grade, ...
Malignant Vascular Tumors Hemangiopericytoma   Pericytes of    Zimmerman   25% in head and neck   Surgical treatment  ...
Malignant Vascular Tumors Kaposi’s Sarcoma   Viral-induced   Four entities       Classic       Endemic       Immunos...
Paragangliomas Named for anatomic location Arise in paraganglionic tissue (neural crest) Type I cells (chief) – APUD ce...
Cervical Thymic Cysts Failure of involution of the cervical  thymopharyngeal ducts. Firm, mobile masses found in the low...
Dermoid Cysts Mesoderm and Ectoderm Midline, paramedian, painless masses that  usually do not elevate with tongue  protr...
Teratoid Cysts and Teratomas All three germ cell layers- Endoderm,    mesoderm and ectoderm.   Larger midline masses, pr...
Laryngoceles Congenitally from an enlarged laryngeal  saccule. Classified as internal, external, or both Internal   Co...
Plunging Ranula Simple ranula- unilateral oral cavity cystic lesion. Plunging ranula- pierce the mylohyoid to present  a...
Sternomastoid Tumor ofInfancy Firm mass of the SCM,(Pseudotumor) chin turned away and    head tilted toward the mass.   ...
Infectious and InflammatoryLesions 40% of infants have palpable LAD 55% of pediatric patients. Most commonly involving ...
Lymphadenitis    Very common, especially within 1st decade    Tender node with signs of systemic infection    Directed ...
Lymphadenopathy Equivocal or suspicious FNAB in the pediatric  nodal mass requires open excisional biopsy to  rule out ma...
Granulomatous lymphadenitis Infection develops over weeks to months Minimal systemic complaints or findings Common etio...
Granulomatous lymphadenitis Typical M. tuberculosis         Atypical M. tuberculosis   more common in                 ...
Granulomatouslymphadenitis Cat-scratch fever  (Bartonella)   Pediatric group   Preauricular and    submandibular nodes ...
Bacterial Cervical Adenitis Tender, enlarged nodes Organisms- Staphylococcus, Group A  Streptococcus Treatment- Beta-la...
Viral Adenitis Most common infectious process in the neck. Rhinovirus, adenovirus, enterovirus.
Summary   Extensive differential diagnosis   Age of patient is important   Accurate history and complete exam essential...
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Evaluation of neck tumors

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Differential Diagnoses of Neck Masses

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Evaluation of neck tumors

  1. 1. EVALUATION OF THE NECK Frederick Mars Untalan MD
  2. 2. Lymphoma More common in children and young adults Up to 80% of children with Hodgkin’s have a neck mass Signs and symptoms  Lateral neck mass only (discrete, rubbery, nontender)  Fever  Hepatosplenomegaly  Diffuse adenopathy
  3. 3. Lymphoma FNAB – first line diagnostic test If suggestive of lymphoma – open biopsy Full workup – CT scans of chest, abdomen, head and neck; bone marrow biopsy
  4. 4. Salivary Gland Tumors Enlarging mass anterior/inferior to ear or at the mandible angle is suspect Benign  Asymptomatic except for mass Malignant  Rapid growth, skin fixation, cranial nerve palsies
  5. 5. Salivary Gland Tumors Diagnostic tests  Open excisional biopsy (submandibulectomy or parotidectomy) preferred  FNAB  Shown to reduce surgery by 1/3 in some studies  Delineates intra-glandular lymph node, localized sialadenitis or benign lymphoepithelial cysts  Accuracy >90% (sensitivity: ~90%; specificity: ~80%)  CT/MRI – deep lobe tumors, intra vs. extra-parotid Be prepared for total parotidectomy with possible facial nerve sacrifice
  6. 6. Carotid Body Tumor Rare in children Pulsatile, compressible mass Mobile medial/lateral not superior/inferior Clinical diagnosis, confirmed by angiogram or CT Treatment  Irradiation or close observation in the elderly  Surgical resection for small tumors in young patients  Hypotensive anesthesia  Preoperative measurement of catecholamines
  7. 7. Carotid paragangliomas
  8. 8. Carotid paragangliomas Treatment  Surgery  Mortality 8%, >5cm tumors had more complications  Preop workup key – vascular surgeon, anesthesia  Embolization – controversial  Radiation
  9. 9. Vagal paragangliomas Most commonly at nodose ganglion Painless mass at angle of mandible present for many years – enlarging may get Horner’s, CN XII, hoarseness More multicentric (25%) Malignancy (18%) None produce catecholamines
  10. 10. Vagal paragangliomas
  11. 11. Lipoma Soft, ill-defined mass Usually >35 years of age Asymptomatic Clinical diagnosis – confirmed by excision
  12. 12. Neurogenic Tumors Arise from neural crest derivatives Include schwannoma, neurofibroma, and malignant peripheral nerve sheath tumor Increased incidence in NF syndromes Schwannoma most common in head & neck
  13. 13. Schwannoma Sporadic cases mostly 25 to 45% in neck when extracranial Most commonly between 20 and 50 years Usually mid-neck in poststyloid compartment Signs and symptoms  Medial tonsillar displacement  Hoarseness (vagus nerve)  Horner’s syndrome (sympathetic chain)
  14. 14. Congenital & Developmental Mass  Epidermal and sebaceous cysts  Branchial cleft cysts  Thyroglossal duct cyst  Vascular tumors
  15. 15. Epidermal and Sebaceous Cysts Most common congenital/developme ntal mass Older age groups Clinical diagnosis  Elevation and movement of overlying skin  Skin dimple or pore Excisional biopsy confirms
  16. 16. Branchial Cleft Cyst 2nd cleft most common (95%) – tract medial to cnXII between internal and external carotids 1st cleft less common – close association with facial nerve possible 3rd and 4th clefts rarely reported Present in older children or young adults often following URI
  17. 17. Branchial Cleft Cyst  Most common as smooth, fluctuant mass underlying the SCM  Skin erythema and tenderness if infected  Treatment  Initial control of infection  Surgical excision, including tract  May necessitate a total parotidectomy (1st cleft)
  18. 18. Thyroglossal Duct Cyst Most common congenital neck mass (70%) 50% present before age 20 Midline (75%) or near midline (25%) Usually just inferior to hyoid bone (65%) Elevates on swallowing/protrusion of tongue Treatment is surgical removal (Sistrunk) after resolution of any infection
  19. 19. Thyroglossal Duct Cyst Most common congenital midline mass Ectopic thyroid tissue vs. thyroglossal duct cyst Asymptomatic mass at or below the hyoid bone that elevates with tongue protrusion. Ultrasound Thyroid Scan in patients that do not demonstrate a normal thyroid by US.
  20. 20. Vascular Tumors Lymphangiomas and hemangiomas Usually within 1st year of life Hemangiomas often resolve spontaneously lymphangiomas remain unchanged CT/MRI may help define extent of disease
  21. 21. Vascular Birthmarks Classification system  Hemangioma vs. malformation  Based on clinical, cellular, biologic factors  Older terms – “capillary”, “juvenile”, “strawberry”, “cavernous”
  22. 22. VascularBirthmarks
  23. 23. Hemangiomas Most common tumor of infancy (10%) Slight female predominance 60% arise in head and neck – cosmetic concerns
  24. 24. Hemangiomas Clinical presentation for diagnosis  Not seen at birth  Precursor lesion  Proliferative phase  Involution phase  Superficial vs. deep
  25. 25. Complications from Hemangiomas Occur in 20%  Ulceration  Compression of vital structures  High-output cardiac failure  Bleeding  Kasabach-Merritt syndrome
  26. 26. Laryngeal Hemangiomas Usually in the subglottis Healthy infant with biphasic stridor (croup) Behave similarly 50% with cutaneous counterpart
  27. 27. Treatment of Hemangiomas Why and when to treat?  Normal skin in 50% that involute within 5 years  Other 50%-- 80% substantial deformity Pro’s and Con’s
  28. 28. Treatment of Hemangiomas Observation  Serial photography important to document involution  Regular visits with reassurance
  29. 29. Treatment of Hemangiomas  Systemic steroids  Careful selection criteria  Prednisone 2-4mg/kg for up to 6 weeks  Varied results (30%)  Side effects
  30. 30. Treatment of Hemangiomas Intralesional steroids  Usually for vision threatening lesions  Combination of beta- methasone and triamcinolone
  31. 31. Treatment for Hemangiomas Surgery  Eyelid lesions, bulky lesions, vermillion border, nasal tip, eyebrow  CO2 laser for subglottis Arterial embolization Radiation therapy Alpha-2b interferon
  32. 32. Vascular malformations Capillary, venous, arterial, lymphatic, mixed By definition– present at birth No proliferative or involution phase Commensurate growth
  33. 33. Capillary malformations  Older term– “port- wine stain”  Usually in trigeminal distribution  Most isolated anomalies  Sturge-Weber syndrome
  34. 34. Treatment of CapillaryMalformations Cosmetic concealing makeup Tattooing Surgical excision (tissue expanders) Pulse dye-laser
  35. 35. Venous Malformations  Diagnosis is clinical – palpation  Treatment dependent on location (surgery and sclerotherapy)
  36. 36. Vascular Tumors(lymphangioma) Older terms– “cystic hygroma”, “lymphangioma” Can expand with URI Surgical treatment is mainstay  Picibanil (OK-432)
  37. 37. Arteriovenous malformations Usually clinically apparent Embolization and surgical resection
  38. 38. Nasopharyngeal Angiofibroma Most common benign tumor of nasopharynx Older term– “juvenile nasopharyngeal angiofibroma”, “JNA” Presentation: recurrent epistaxis/nasal congestion, hearing loss, orbital, CN Arise where sphenoidal process of palatine bone meets horizontal ala of vomer
  39. 39. Nasopharyngeal Angiofibroma Diagnosis is made by clinical and radiographic findings CT/MRI Biopsy- rarely indicated Angiography
  40. 40. Nasopharyngeal Angiofibroma Angiography Histology
  41. 41. Nasopharyngeal Angiofibroma Treatment  Embolization and surgery  Autologous blood/Cell Saver  Approaches  Transnasal endoscopic, lateral rhinotomy/MFD with medial maxillectomy or LeFort I, transpalatal, facial translocation/maxillary swing, infratemporal approaches, craniotomy  Radiation therapy  Chemotherapy
  42. 42. Malignant Vascular Tumors Angiosarcoma  Extremely rare (50% in head and neck)  Prognosis on tumor size, grade, margins  Radiation minimally effective  Sinonasal tract less aggressive  Poor survival
  43. 43. Malignant Vascular Tumors Hemangiopericytoma  Pericytes of Zimmerman  25% in head and neck  Surgical treatment  Grade important on prognosis  Radiation/chemotherap y for selected cases
  44. 44. Malignant Vascular Tumors Kaposi’s Sarcoma  Viral-induced  Four entities  Classic  Endemic  Immunosuppressed  AIDS-related  Surgery, chemo, radiation, sclerotherapy
  45. 45. Paragangliomas Named for anatomic location Arise in paraganglionic tissue (neural crest) Type I cells (chief) – APUD cells – catecholamines Type II cells (sustentacular) Clusters together– “Zellballen” Malignancy is clinical
  46. 46. Cervical Thymic Cysts Failure of involution of the cervical thymopharyngeal ducts. Firm, mobile masses found in the lower aspects of the neck. CXR, CT scan
  47. 47. Dermoid Cysts Mesoderm and Ectoderm Midline, paramedian, painless masses that usually do not elevate with tongue protrusion. Commonly misdiagnosed as Thyroglossal Duct Cysts. Treatment is simple surgical excision
  48. 48. Teratoid Cysts and Teratomas All three germ cell layers- Endoderm, mesoderm and ectoderm. Larger midline masses, present earlier in life. 20% associated maternal polyhydramnios Unlike adult teratomas, they rarely demonstrate malignant degeneration. Surgical excision.
  49. 49. Laryngoceles Congenitally from an enlarged laryngeal saccule. Classified as internal, external, or both Internal  Confined to larynx, usually involves the false cord and aryepiglottic fold.  Hoarseness and respiratory distress vs. neck mass.
  50. 50. Plunging Ranula Simple ranula- unilateral oral cavity cystic lesion. Plunging ranula- pierce the mylohyoid to present as a paramedian or lateral neck mass. Cyst aspirate- high protein, amylase levels CT scan/MRI Treatment is intra-oral excision to include the sublingual gland of origin.
  51. 51. Sternomastoid Tumor ofInfancy Firm mass of the SCM,(Pseudotumor) chin turned away and head tilted toward the mass. Hematoma with subsequent fibrotic replacement. Ultrasound Physical therapy is very successful. Myoplasty of the SCM only if refractory to PT.
  52. 52. Infectious and InflammatoryLesions 40% of infants have palpable LAD 55% of pediatric patients. Most commonly involving the submandibular and deep cervical nodes.
  53. 53. Lymphadenitis  Very common, especially within 1st decade  Tender node with signs of systemic infection  Directed antibiotic therapy with follow-up  FNAB indications (pediatric)  Actively infectious condition with no response  Progressively enlarging  Solitary and asymmetric nodal mass  Supraclavicular mass (60% malignancy)  Persistent nodal mass without active infection
  54. 54. Lymphadenopathy Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease
  55. 55. Granulomatous lymphadenitis Infection develops over weeks to months Minimal systemic complaints or findings Common etiologies  TB, atypical TB, cat-scratch fever, actinomycosis, sarcoidosis Firm, relatively fixed node with injection of skin
  56. 56. Granulomatous lymphadenitis Typical M. tuberculosis  Atypical M. tuberculosis  more common in  Pediatric age groups adults  Anterior triangle  Posterior triangle nodes nodes  Brawny skin,  Rarely seen in our population induration and pain  Usually responds to  Usually responds to anti-TB medications complete surgical  May require excisional excision or biopsy for further curettage workup
  57. 57. Granulomatouslymphadenitis Cat-scratch fever (Bartonella)  Pediatric group  Preauricular and submandibular nodes  Spontaneous resolution with or without antibiotics
  58. 58. Bacterial Cervical Adenitis Tender, enlarged nodes Organisms- Staphylococcus, Group A Streptococcus Treatment- Beta-lactamase resistant antibiotic Fine Needle Aspiration
  59. 59. Viral Adenitis Most common infectious process in the neck. Rhinovirus, adenovirus, enterovirus.
  60. 60. Summary Extensive differential diagnosis Age of patient is important Accurate history and complete exam essential FNAB – invaluable diagnostic tool Possibility for malignancy in any age group Close follow-up and aggressive approach is best for favorable outcomes

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