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 symptoms Lateral neck mass only (discrete, rubbery, nontender) Fever Hepatosplenomegaly Diffuse adenopathy
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
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
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
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
Carotid paragangliomas Treatment Surgery Mortality 8%, >5cm tumors had more complications Preop workup key – vascular surgeon, anesthesia Embolization – controversial Radiation
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
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 sheath tumor Increased incidence in NF syndromes Schwannoma most common in head & neck
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)
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
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
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)
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
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.
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
Vascular Birthmarks Classification system Hemangioma vs. malformation Based on clinical, cellular, biologic factors Older terms – “capillary”, “juvenile”, “strawberry”, “cavernous”
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 is mainstay Picibanil (OK-432)
Arteriovenous malformations Usually clinically apparent Embolization and surgical resection
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
Nasopharyngeal Angiofibroma Diagnosis is made by clinical and radiographic findings CT/MRI Biopsy- rarely indicated Angiography
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
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
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
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.
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.
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.
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.
Infectious and InflammatoryLesions 40% of infants have palpable LAD 55% of pediatric patients. Most commonly involving the submandibular and deep cervical nodes.
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
Lymphadenopathy Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease
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
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
Granulomatouslymphadenitis Cat-scratch fever (Bartonella) Pediatric group Preauricular and submandibular nodes Spontaneous resolution with or without antibiotics
Bacterial Cervical Adenitis Tender, enlarged nodes Organisms- Staphylococcus, Group A Streptococcus Treatment- Beta-lactamase resistant antibiotic Fine Needle Aspiration
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 FNAB – invaluable diagnostic tool Possibility for malignancy in any age group Close follow-up and aggressive approach is best for favorable outcomes