Neck Mass Pop

8/6/2019 Neck Mass Pop

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ProblemProblem--base learningbase learning

Neck MassNeck Mass


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CaseCase : 40

.

ChiefComplaint : 4


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Present illness

4 PTA


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Past history


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MoreHistory ?


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PhysicalPhysical

examinationexamination


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Physical examinationPhysical examination

GAGA::AA thaithai female, good consciousness,female, good consciousness,notnot pale,nopale,no jaundicejaundice

Vital signs :Vital signs :

BT =BT = 3737..22 00CC BP =BP = 120120//8080 mmHgmmHg

RR =RR = 1616/min/min PRPR== 8484 bpmbpm

Heart & lungHeart & lung :: normalnormal

AbdomenAbdomen :: liver and spleen cant beliver and spleen cant bepalpatedpalpated


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ENT examENT exam

NoseNose : normal: normal

NasopharynxNasopharynx : no polyp , no mass seen,: no polyp , no mass seen,nono discharge, not injected,discharge, not injected, notnot swellingswelling

OropharynxOropharynx : tonsil arent enlarged, dental: tonsil arent enlarged, dental caries,caries,nono ulcer, not injected ,ulcer, not injected ,nono swellingswelling

IDLIDL : vocal cord normal movement,: vocal cord normal movement,no noduleno nodule , not injected, not injected


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NeckExaminationNeckExamination

Thyroid gland not enlargementThyroid gland not enlargement

Parotid glandParotid gland normalnormal

Neck mass: (more info next slide)Neck mass: (more info next slide)


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Positive findingPositive finding

HxHx::

44 PTAPTA


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Positive findingPositive finding

PE.PE.

Neck mass :Neck mass :At posterior triangle, irregular surface,

firm, not tender, movable, no sign of inflammation,

no translucency


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Mass :

- posterior triangle

- irregular surface- firm

- not tender

- movable

- no sign of inflammation- no translucency


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Approach to neck massApproach to neck mass


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Neck massNeck mass

IncidenceIncidence

AgeAge

SexSex Duration (Rule of seven)Duration (Rule of seven)

PainPain

General symptomsGeneral symptoms


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EtiologyEtiology

0-15 years 16-40 years >40 years

Inflammatory Inflammatory Malignant

Congenital

developmental

Congenital

developmentalBenign

Neoplasm-

malignant Neoplasm-benign Inflammatory

Benign MalignantCongenital

developmental


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Medical Student Gr. 5A

Rule ofRule of 8080ss

Older thanOlder than 4040 yearsyears oldold

8080% of all% of all nonthyroidnonthyroid neck masses areneck masses are neoplasticneoplastic

8080%of these

%of these neoplasmsneoplasms are malignantare malignant

8080% of these malignant lesions are metastatic lesions% of these malignant lesions are metastatic lesions

8080% of these metastatic lesions arise from primaries% of these metastatic lesions arise from primaries

that are above the claviclethat are above the clavicle


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History of cancerHistory of cancer

,,,, 44-- 66


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Physical examinationPhysical examination

Local examinationLocal examination

Regional examinationRegional examination

General examinationGeneral examination


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Local examinationLocal examination

Location (midline or lateral)Location (midline or lateral)

SizeSize

ShapeShape SurfaceSurface

ConsistencyConsistency

TendernessTenderness MobilityMobility

PulsationPulsation


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Midline massMidline mass

ThyroglossalThyroglossal duct cystduct cyst

Isthmus of thyroidIsthmus of thyroid

Pharyngeal pouchPharyngeal pouch SubhyoidSubhyoid bursabursa

DelphianDelphian nodenode

LaryngoceleLaryngocele Ectopic thyroidEctopic thyroid


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Lateral neck massLateral neck mass

NonNon--lymph nodelymph node

Lymph nodeLymph node


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NonNon--lymph nodelymph node

Solitary thyroid noduleSolitary thyroid nodule

Branchial cleft anomaliesBranchial cleft anomalies

Cystic hygromaCystic hygroma Carotid body tumorCarotid body tumor

LipomaLipoma

NeurilemmomaNeurilemmoma Swelling of salivary glandSwelling of salivary gland


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InfectionInfection

--acute (pyogenic)acute (pyogenic)

--chronic (Tuberculosis,atypicalchronic (Tuberculosis,atypicalmycobacterium,cat scrath fever)mycobacterium,cat scrath fever)

Primary neoplasmPrimary neoplasm

-- Hodgkins lymphomaHodgkins lymphoma-- NonNon--HodgkinsHodgkins


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Metastatic nodeMetastatic node

-- Head and neck cancerHead and neck cancer

-- BelowBelow clavicularclavicular cancer (cancer (lung,GI,etclung,GI,etc.).)-- Unknown primaryUnknown primary


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Lymph node drainageLymph node drainage


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Cervical node region and possible origin

of primary neoplasm

Lymph node Primary

Submandibular

Posterior cervical

Supraclavicular

Upper jugular

Middlejugular

Low jugular

Lower lip,floor of mouth,tongue

(anterior),Tonsil,buccal mucosa,gingiva

Nasopharynx,thyroid,lateral pharyngeal wall

Below the clavicle

Tongue(lateral and posterior),palate,tonsil

Pharynx,larynx,piriform sinus,thyroid

Esophagus (cervical segment)


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InvestigationInvestigation

CBCCBC

Chest XChest X--rayray

FlexibleFlexible rhinolaryngoscoperhinolaryngoscope,, nasopharyngoscopenasopharyngoscope UltrasonographyUltrasonography

DirectDirect laryngoscope,bronchoscopelaryngoscope,bronchoscope,,

esophagoscopeesophagoscope


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Fine needle aspirationFine needle aspiration

Sialography,MRISialography,MRI

BiopsyBiopsy Syphilis,AIDSSyphilis,AIDS


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Diffential diagnosisDiffential diagnosis


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Diffential diagnosisDiffential diagnosis

Lymphoma ( primary neoplasm )Lymphoma ( primary neoplasm )

TuberculousTuberculous lymphadenitislymphadenitis

Metastatic lymph node neoplasmMetastatic lymph node neoplasm LipomaLipoma


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lymphomalymphoma

NonNon--hodgkinshodgkins ProgressiveProgressive clonalclonal expansion Bexpansion B--cell , Tcell , T--cell , NKcell , NK

m/c hematopoietic neoplasm (m/c hematopoietic neoplasm ( 55 times of HD )times of HD ) PainlessPainless adenopathyadenopathy , fatigue and weakness, fatigue and weakness

B symptoms : fever , night sweat , lost weightB symptoms : fever , night sweat , lost weight

HepatosplenomegalyHepatosplenomegaly Noncontiguous pattern of spreadingNoncontiguous pattern of spreading


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Hodgkins diseaseHodgkins disease

Predominant BPredominant B--cellcell malinancymalinancy

Bimodal age distribution :Bimodal age distribution : 33rd decade , aroundrd decade , around 6060

Common present with cervicalCommon present with cervical adenopathyadenopathy B symptom ,B symptom , pruritispruritis ,, hepatosplenomegalyhepatosplenomegaly ,,

PelPel EbsteinEbstein fever , Alcoholfever , Alcohol--induced pain ( rareinduced pain ( rare

butbut hignhign specificity )specificity ) contiguous pattern of spreadingcontiguous pattern of spreading


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TuberculousTuberculous lymphadenitislymphadenitis

m/c site : neck along them/c site : neck along the sternocleidomastoidsternocleidomastoid m.m.

, posterior cervical and, posterior cervical and supraclavicularsupraclavicular sites.sites.

The most common presentation ofThe most common presentation ofextrapulmonaryextrapulmonary tuberculosistuberculosis

Painless , Advanced may suppurate and form aPainless , Advanced may suppurate and form a

drainagedrainage particularly frequent among HIVparticularly frequent among HIV--infectedinfected

patientspatients


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lipomalipoma

BenignBenignAll age m/c adultAll age m/c adult

Soft , not tenderSoft , not tender

slippery , not attach to skinslippery , not attach to skin

Vary of sizeVary of size

Solitary nodule is commonSolitary nodule is common

Treatment : conservative except tender or rapidTreatment : conservative except tender or rapid

growth (growth ( SxSx common for cosmetics ) ,common for cosmetics ) ,

liposuctionliposuction recurrentrecurrent


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investigateinvestigate


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CBCCBC

Chest X rayChest X ray

FNABFNAB


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HbHb 1111..99 g/dL , Hctg/dL , Hct 3434..33%%

WBC countWBC count 99,,500500//LL WBC differentialWBC differential

NeutrophilNeutrophil 6363 %%

LymphocyteLymphocyte 3232 %% Atypical LymphocyteAtypical Lymphocyte 22%%

MonocyteMonocyte 22 %%

RBCRBC 55..33 xx 101066 //LL PleteletPletelet 350350,,000000//LL Normocytic normochromic RBCNormocytic normochromic RBC

CBCCBC


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Chest XChest X--rayray


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FNAFNA

Moderate amount of small matureModerate amount of small mature

lymphocytelymphocyte

A few plasma cellA few plasma cell

No evidence of malignancy seenNo evidence of malignancy seen


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Manageme

nt


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Neck mass

Hx & PEENT exam

Biopsy

CXRCBCFNA

-

+

+

-

Panendoscope

Biopsy 4-5 points+ Nasopharynx exam , biopsy

PF

BOT

Supraglottis

Tonsils

-


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-

PanendoscopeBiopsy 4-5 points

+ Nasopharynx exam , biopsy

Unknown 10

Open biopsy

+ frozen Section

+ Radical neck dissection , chemo


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Management nextManagement next

Excisional biopsyExcisional biopsy

Management


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ExcisionalExcisional biopsybiopsy


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Pathology finding : 4xPathology finding : 4x


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Pathology finding :Pathology finding : 1010xx


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Pathology finding 40xPathology finding 40x


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Pathology findingPathology finding 4040xx


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Whats definite diagnosis?Whats definite diagnosis?

Tuberculous lymphadenitisTuberculous lymphadenitis


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TreatmentTreatment

Anti TB drugsAnti TB drugs

Supportive treatmentSupportive treatment educationeducation


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TheEnd.Thank for yourattention


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QuestionQuestion

11.. midlinemidlineneck massneck mass 33 lateral neck masslateral neck mass 33

22..neck massneck mass

((congenital,infection,trauma,tumorcongenital,infection,trauma,tumor


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QuestionQuestion 33..malignancymalignancy

44.Investigation.Investigation

55..malignancymalignancyexcisionalexcisionalbiopsybiopsy biopsybiopsyprimary lesionprimary lesion

Neck Mass Pop

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