Ent clinical rotation presentation neck masses by xavier

ENT CLINICAL ROTATION
PRESENTATION
Thursday, December 8, 2016Neck masses by RUTAYISIRE François Xavier
1
TOPIC: MANAGEMENT OF NECK MASSES
PRESENTED BY: RUTAYISIRE François
Xavier
LEVEL 5(DOC III)MEDICAL STUDENT AT UR.
November 30th 2016

A neck mass is any abnormal
enlargement, swelling, or
growth from the level of the
base of skull to the clavicles .
Definition
Definition
Definition
2

3
 The location of the mass can focus the differential.
 Familiarity with neck anatomy is critical for
diagnosis and management of disease processes
affecting this region.
 The neck is traditionally divided into the central and
the lateral necks, with the lateral neck further
subdivided into anterior and posterior triangles

The anterior triangle
is delineated by :
1. The anterior border of the SCM
laterally,
2. The midline medially,
3. The lower border of the
mandible superiorly.
The SCM divides each
side of the neck into two
major triangles, anterior
and posterior.

The borders of the
posterior triangles are :
1. The posterior border of the
SCM anteriorly,
2. The clavicle inferiorly,
3. The anterior border of the
trapezius muscle posteriorly.
5

6

The thyroid gland :
is usually palpable in the
midline below the thyroid
cartilage.
The parotid glands :
are located in the preauricular
area on each side in the lateral
neck. The tail of each parotid
gland extends below the angle
of the mandible, inferior to the
earlobe.
7

Submandibular
glands : are located within a
triangle bounded by ….
the sternocleidomastoid
muscle, the posterior belly of
the digastric muscle, and the
body of the mandible.
Lymph nodes :
are located throughout
the head and neck
region .
8

FIGURE 2. Lymph node groups with the most likely sites of the primary
lesion.

The evaluation of any neck mass
begins with a careful HISTORY . The
history should be taken with the
differential diagnosis in mind because
directed questions can narrow down
the diagnostic possibilities and focus
subsequent investigations. For
example, in younger patients, one
would tend to look for congenital
lesions, whereas in older adults, the
first concern would always be
neoplasia.
10

Differential diagnosis
11
 It is helpful to consider the differential diagnosis in
three broad categories:
●Congenital
●Inflammatory
●Neoplastic

RULE OF SEVEN....
12
1. Mass present for seven days is inflammatory.
2. Mass present for seven months is neoplastic.
3. Mass present for seven years is congenital.

the differential diagnosis
13

14
 Additionally, patterns of lymph node drainage can
identify areas of concern when metastatic disease is
suspected.

The localization of lymph nodes in the
neck
15

CONGENITAL NECK MASS
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 Usually present at birth, but may present at any age.
 Most common noninflammatory neck mass in children.
 Malgnancy in adult until proven otherwise
 Cystic lesions such as branchial cleft cysts can present in
adulthood, and should be investigated to ensure
malignancy is not present.
 Carcinomas of the tonsil, tongue base, and thyroid may
all present as cystic neck masses.

Congenital/developmental masses –
Midline&Lateral
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 Thyroglossal cysts
 Cystic hygromas
 Branchial cysts
 Plunging ranulas
 Dermoid cysts

TGDC
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 Midline anterior neck.
 Rounded with a diameter of 2-4cm
 Diagnosed in childhood, but up to 40 percent may
present after age 20
 Asymptomatic except when infected by URTI
 Move with tongue protrusion
 Rarely carcinoma develop in cyst.

 Endoderm of the floor
of mouth between the
1st and 2nd archs.
 Descends as a bilobed
diverticulum from the
foramen cecum
around the 4th week to
rest by the 7-8th week.
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EMBRYOLOGY

Management of TGDC
20
 Excision to confirm the diagnosis and to prevent
future infections.
 The Sistrunk operation is the procedure of choice.
 Thyroid carcinoma can be present in (1 to 2%) of
thyroglossal duct cysts,
 All thyroglossal duct cysts and tracts should undergo
a careful histologic examination

Cystic hygromas (lymphangiomas)
21
 Cystic hygromas are present as soft, fluctuant and
transilluminable masses just under the skin.
 Nearly all present by the age of 2 to 3 years, with
60% occurring in the head and neck region (usually
in the posterior triangle) and most presenting at
birth.
 They are multiloculated and painless.
 Ultrasound is useful to confirm the diagnosis and CT
scanning is essential if surgery is contemplated.

Ectopic Thyroid
 90% are lingual
 Symptoms are of base of tongue obstruction,
dysphagia
 Surgical Excision

Plunging Ranula
 A ranula is a mucocele or retention cyst arising
from an obstruction in the sublingual glands in the
floor of mouth.
 Simple ranula- unilateral oral cavity cystic lesion
 Painless and slow-growing.
 They are most often located in the submentum.
 When they extend through the mylohyoid muscle
into the neck they are referred to as "plunging
ranula".

Management
24
 Plunging ranula- pierce the mylohyoid to present as
a paramedian or lateral neck mass.
 CT scan/MRI
 Treatment is intraoral excision to include the
sublingual gland of origin.

Branchial cleft cyst
25
 Almost 20 percent of pediatric neck masses.
 Present in late childhood or early adulthood when a
previously unrecognized cyst becomes infected.
 Only a very small percentage first present in adulthood.
 Relatively consistent in their location in the neck,
anterior to the SCM.
 †Painless swelling
 †Young adults†
 M= F ratio
 Unilateral, 75% on left side

Embryology
 At the 4th week of embryonic life, the
development of 4 branchial (or
pharyngeal) clefts results in 5
branchial (or pharyngeal) arches,
 The second arch grows caudally and,
ultimately, covers the third and
fourth arches.
 The buried clefts become ectoderm-
lined cavities, which normally
involute around week 7 of
development. If a portion of the cleft
fails to involute completely, the
entrapped remnant forms an
epithelium-lined cyst with or without
a sinus tract to the overlying skin.
26
Pathophysiology

Branchial cleft cyst
27

First branchial cleft cysts
28
 Account for less than 1 percent of branchial cleft anomalies.
 They typically appear on the face near the auricle.
 Divided into types I and II
 Type I first branchial cleft cysts are duplication anomalies of
the external auditory canal and are of ectodermal origin.
 They pass through the parotid gland often in close proximity
to the facial nerve.
 Type II branchial cleft cysts are more common and typically
present below the angle of the mandible.
 They contain both ectoderm and mesoderm and pass through
the parotid gland medial or lateral to the facial nerve and end
either inferior to the external auditory canal or at the bony
cartilaginous junction of the external auditory canal.

Second Branchial Cleft Cysts
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 Most Common (90%) branchial anomaly
 Painless, fluctuant mass in anterior triangle
 Inferior-middle 2/3 junction of SCM, deep to
platysma, lateral to IX, X, XII, between the internal
and external carotid and terminate in the tonsillar
fossa
 Surgical treatment may include tonsillectomy

Third Branchial Cleft Cysts
 Rare (<2%)
 Similar external presentation to 2nd BCC
 Courses cephalad to the superior laryngeal nerve
through the thyrohyoid membrane, medial to IX,
lateral to X, XII, posterior to internal carotid
 Surgical approach must visualize recurrent
layngeal nerves- Thyoidectomy incision

Fourth Branchial Cleft Cysts
 Courses from pyriform sinus apex caudal to superior
laryngeal nerve, to emerge near the cricothryoid
joint, and descend superficial to the recurrent
laryngeal nerve.

Management
32
 Management of branchial cleft cysts begins with
controlling infection, if present.
 Once the infection has resolved, the mass is usually
excised to prevent future problems

Thymic Cyst
 Thymus develop from 3rd pharyngeal pouch and
descend to neck to the mediastinum.
 Thymic remnants may persist anywhere in its
path from angle mandible to midline of neck.
 Swelling either cystic or solid.
 Can occur in children or adults by presents of
anterior neck mass and deep to middle SCM.
 Rare condition
 Tx: Surgical excision + sternotomy if extend into
mediastinum.

34

Sublingual Dermoid Cyst
 Midline submental swelling but does NOT move on
protrusion of tongue.
 Can be arises from floor of mouth and need to be
diffrentiated with ranula.
 Tx: Surgical excision

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.

Infective and inflammatory masses
37
 Infectious inflammatory disorders
 - Reactive viral lymphadenopathy
 - Bacterial lymphadenopathy
 - Parasitic lymphadenopathy
 Noninfectious inflammatory disorders

Mycobacterial lymphadenitis
38
 Mycobacterial lymphadenitis should be suspected in
an acute lymphadenitis, with only mild tenderness
and a partial response to antibiotics.
 Other rare granulomatous causes of adenopathy
include cat scratch disease and actinomycosis.

HIV infection
39
 Cervical lymphadenopathy is very common in
patients with HIV infection.
 Lymphadenopathy syndrome is a mild form of HIV
disease that represents one of the initial stages of the
infection.
 Patients can remain stable for months to years, with
little in the way of symptoms.
 This diagnosis should be considered in any adult
with persistent generalised lymphadenopathy and
the relevant risk factors.

Acute sialadenitis
40
 Acute infection of the salivary glands can be bacterial
or viral in origin.
 Bacterial sialadenitis occurs more frequently in the
parotid glands, is more common in the elderly and is
associated with reduced salivary flow from
dehydration.

Management
41
 Treatment is with broad-spectrum antibiotics
covering S. aureus, the most common pathogen
causing infection of the salivary glands, in addition
to supportive measures (rehydration, analgesics and
gland massage to encourage salivary flow).
 Appropriate antibiotics include flucloxacillin,
cephalexin and clindamycin.
 Surgical drainage may be required if an abscess
develops.

Viral sialadenitis
42
 Most commonly due to the mumps virus, which
typically affects the parotid glands bilaterally.
 The mumps virus most often affects children, with
peak incidence at ages 4 to 6 years.
 Other causes include coxsackievirus,
cytomegalovirus and HIV

Thyroiditis
43
 The most common inflammatory goitre is
Hashimoto’s thyroiditis.
 Autoantibodies against thyroid peroxidase are
produced, resulting in lymphocytic infiltration of the
thyroid and eventually a goitre, which is typically
firm and rubbery.
 Management by an endocrinologist is usually
necessary because of the initial hyperthyroidism and
subsequent hypothyroidism.
 Occasionally surgery is required for obstructive
symptoms.

NEOPLASTIC DISORDERS
44
Metastatic head and neck carcinoma
 Squamous cell carcinoma
 Thyroid Cancer
 Salivary gland malignancy
 Paragangliomas
 Schwannoma
 Lymphoma
 Lipoma.

 SCC is the most common cause of
a malignant neck lump.
 Metastatic SCC most commonly
arises from the mucosa of the
upper aerodigestive tract (oral
cavity, nasopharynx, oropharynx
and laryngopharynx).
 Cutaneous malignancies (SCC
and melanoma) may also
metastasise to the parotid gland
or lateral cervical lymph nodes,
sometimes years after the
primary tumour was excised.
45
Squamous cell carcinoma

Lymphoma
46
 The nodes are typically ‘rubbery’ in consistency.
Associated symptoms include night sweats, lethargy
and weight loss.
 Lymphoma is the most common cause of a
malignant neck lump in children and should
therefore, despite being rare, be considered in the
differential diagnosis of any progressive or persistent
childhood lymphadenopathy.
 FNAB and CT scan are indicated, with referral to a
haematologist if cytology is suggestive of lymphoma

Adenocarcinoma
47
 Adenocarcinoma is a type of cancer that forms in mucus-
secreting glands throughout the body.
 Metastatic adenocarcinoma to the upper cervical lymph
nodes may originate from the salivary glands or
sinonasal cavity.
 Metastatic adenocarcinoma in the lower neck may arise
from a site below the clavicles (e.g. lung, oesophagus or
stomach).
 Virchow’s node (also referred to as Troisier’s sign) refers
to metastatic adenocarcinoma occurring in the left
supraclavicular fossa and usually arising from the
stomach

Thyroid cancer
48
 Most thyroid cancers present clinically with a
palpable thyroid nodule, which is often
asymptomatic. About half of thyroid cancers are
initially noticed by the patient, whereas the
remainder are detected during routine physical
examination, by chance on imaging studies often for
unrelated medical conditions or during surgery for
benign thyroid disease.
 Occasionally thyroid cancer can present with a
metastatic neck node, and the diagnosis is confirmed
on FNAB.

Management
49
 When thyroid cancer is suspected or demonstrated
on FNAB, prompt referral to a ENT surgeon is
warranted.
 Total thyroidectomy and adjuvant iodine ablation
therapy is indicated for most patients diagnosed with
thyroid cancer.

Salivary gland malignancy
50
 Salivary gland cancers include adenocarcinoma and
metastatic cutaneous SCC.
 Symptoms and signs that suggest malignancy
include pain, rapid growth, a hard mass, fixity to the
skin or mandible and facial nerve palsy. FNAB and
CT/MRI scanning are essential to assess the extent
of disease and to plan surgery.
 High-grade salivary gland malignancy often requires
neck dissection and postoperative radiotherapy.

Carotid body tumours
51
 Carotid body tumours are rare benign tumours of the
carotid body neural plexus.
 They usually present as a painless pulsatile mass at the
level of the carotid bifurcation, and typically can be
moved side to side but not vertically.
 The tumours are extremely vascular, and are diagnosed
using a combination of CT scan, MRI, magnetic
resonance angiography and carotid doppler scanning.
 Following comprehensive assessment, surgery is usually
performed by a head and neck surgeon and a vascular
surgeon.

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