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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.
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