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HEAD AND NECK SURGERY/ DISORDERS OF THE HEAD AND NECK

November 8, 2012

- Common clinical patients- All age groups- Very complex differential diagnosis- Systemic approach essential

Anatomical Considerations

- Prominent landmarks- Triangles of the neck- Carotid bulb- lymphatic levels (lymph nodes)

o II, III, IV : Along the sternocleidomastoido VI : Submental/ submandibular

General Considerations

- Patient ageo Paediatrics (0-15 years old) : 90% benigno Young adult (16- 40 years old) : similar to pediao Late adult (> 40 years ) :rule of 80s

- Locationo Congenital masses : consistent in locationo

Metastatic masses : key to primary lesion

Metastatic Location according to Various Primary Lesions

Diagnostic Steps

- Historyo Developmental time courseo Associated symptoms (dysphagia, otalgia, voice changes)o Personal habits (tobacco, alcohol)o Previous irradiation or surgery

- Physical Examo Complete head and necko Emphasis on location, mobility, and consistency

Empirical Antibiotics- Inflammatory mass suspected- Two weeks trial of antibiotics- Follow up for further investigation

Diagnostic Tests

- Fine needle aspiration (FNAB)- Computed tomography (CT)- Magnetic Resonance Imaging (MRI)- Ultrasonography- Radionucleotide scanning

FNAB

- Standard of diagnosis- Indications:

o Any neck mass that is not an obvious abscesso Persistence after a 2 week course of antibiotics

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- Small gauge needleo Reduces bleedingo Seeding of tumornot a concern

- No contraindication (vascular : vascular if pulsating)1. Proper collection required2. Minimum of 4 separate passes3. Skilled cytopathologist essential4. On- site review best

CT

- Distinguish cystic from solid- Extent of lesion- Vascularity with contrast- Detection of unknown primary (metastatic)- Pathologic node (lucent >1.5 cm; loss of shape)- Avoid contrast in thyroid lesions

MRI

- Best for tumors- Similar information as CT- Better for upper neck and skull base- Vascular delineation with infusion- More expensive- Structure is more emphasized and bony areas less

Ultrasonography

- Less important now with FNAB- Solid vs cystic masses- Congenital cystic...- Noninvasive (pedia)

Radionucleotide scanning

- Salivary and thyroid masses- Location....- ...

Primary tumors

- Thyroid mass- Lymphoma- Salivary tumor- Lipoma- Carotid body- Neurogenic tumor

Thyroid Mass

- Leading cause of anterior neck masses- Children:

o Most common neoplastic conditiono Male predominanceo Higher incidence of malignancy

- Adultso Female predominanceo Mostly benign

- Lymph Node metastasiso Initial symptom in 15% of papillary carcinomao 40% with malignant noduleso Histologically in >90%

- FNAB has replaced USD and radionucleotide scanningo Decreased number of patients with surgeryo Increased number of malignant tumors found at surgeryo Doubled the number of cases followed-upo Unsatisfactory aspiraterepeat in 1 month

Lymphoma- More common in children and young adults- Up to 80% of children with hodgkins have a neck mass- Signs and symptoms

o Lateral neck mass only (discrete, rubbery, nontender)o Fevero Hepatosplenomegalyo Diffused adenopathy

- FNAB: 1stline diagnostic test- If suggestive of lymphoma: open biopsy- Full work upCT scan of chest...

Salivary Gland Tumors

- Enlarging mass anterior/ inferior to ear at the mandible angle is suspected- Benign

o Asymptomatic except for mass- Malignant

o Rapid growth skin fixation, cranial nerve palsies- 1 side swollen: tumor- Both sides swollen: parotitis (mumps)- Diagnostic Tests

o Open excisional biopsyo Submandibulectomy/ parotidectomy preferredo FNAB

Shown to reduce symptoms by 1/3 in some studies Delineates intraglandular lymph node, lymphoepithelial cysts May facilitate surgical planning and patient counselling Accuracy > 90% (sensitivity90%; specificity80%)

o CT/MRI Deep lobe tumorss, intra vs extraparotid

- be prepared for total parotidectomy with possible facial nerve sacrifice (facialnerve is sandwiched by the parotid gland)

Carotid Body Tumor

- Rare in children- Pulsatile, compressible mass- Mobile medial/ lateral; not superior/ inferior- Clinical diagnosis confirmed by angiogram or CT- Treatment

o Surgical resection for small tumors in young patients Hypotensive anesthesia Preoperative measures of catecholamines

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Lipoma

- Soft, ill- defined mass- Usually >35 years old- Asymptomatic- Clinical diagnosis confirmed by excision

Neurogenic Tumor

- Arise from neural crest derivatives- Include schwannoma- Schwannoma most common in head and neck

Schwanomma- Sporadic cases mostly- 25- 45% in neck when extracranial- Most commonly between 20- 50 years- Usually mid- neck in post styloid compartment- Signs and symptoms

o Medial tonsillar displacemento Hoarsenesso Horners syndrome (sympathetic chain)

Congenital and Developmental Mass

- Epidermal and sebaceous cyst- Branchial cleft cysts- Thyroglossal duct cyst- Vascular tumor

Epidermal and Sebaceous Cysts

- Most common congenital developmental mass- Older age groups- Clinical diagnosis

o Elevation and movement of overlying skino Skin dimple/ pore

- Excisional biopsy confirmsBranchial Cleft Cyst

- Branchial cleft anomalies- 2ndcleft most common (95%)

o Tract medial to cranial nerve 12 between internal and external carotids- 1

st

clefts less commonclose association with facial nerve possible- 3rd- 4thclefts rarely reported- Present in older children or young adults after following upper respiratory infection- Most common as smooth, fluctuant mass underlying the sternocleidomasoid

muscle

- Skin erythema and tenderness if infected- Treatment

o Initial control of infectiono Surgical excision, including tract (?)

- May necessitate a total parotidectomy (1stcleft)Thyroglossal Duct Cyst

- Most common congenital neck mass (70%)- 50% present before age 20- Midline (75%) or near midline (25%)- Usually just inferior to the hyoid bone (65%)

- Elevates on swallowing/ protrusion of the tongue- Treatment is surgical removal (sis trunk) after resolution of any infection

Vascular Tumors

- Lymphangiomas and hemangiomas- Usually within 1styear of life- Hemangiomas often resolve spontaneously while lymphangiomas remain

unchanged

- CT/MRI may help define extent of disease- Surgical excision

Inflammatory Disorders- Lymphadenitis- Granulomatous lymphadenitis

Lymohadenitis

- Very common especially within 1stdecade- Tender node with signs of systemic infection- Directed antibody therapy with follow up- FNAB Indications

o Pedia: 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/ suspicious FNAB in...Granulomatous Lymphadenitis

- Infection develops over weeks to months- Minimal, systemic complaints/ findings- Common etiology

o Tuberculosis, atypical TB, cat- scratch fever, actinomycosis, sarcoidosis- Firm, relatively fixed node with infection of skin

Summary

- Extensive differential diagnosis- Age of patient is important- Accurate history and complete exam is essential- FNAB- invaluable diagnostic tool- Possibility for malignancy in any age group- Close follow up and aggressive approach is b est for favourable outcomes.