Transcript neck mass lecture

Anatomical Considerations
Prominent landmarks
Triangles of the neck
Lymphatic levels
 Level 1 contains the submental and submandibular
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nodes.
Level 2 is the upper third of the jugular nodes medial to
the SCM, and the inferior boundary is the plane of the
hyoid bone (clinical) or the bifurcation of the carotid artery
(surgical).
Level 3 describes the middle jugular nodes and is
bounded inferiorly by the plane of the cricoid cartilage
(clinical) or the omohyoid (surgical).
Level 4 is defined superiorly by the omohyoid muscle and
inferiorly by the clavicle.
Level 5 contains the posterior cervical triangle nodes.
Level 6 includes the paratracheal and pretracheal nodes.
Lymphatic levels
Differential diagnosis
A. A. Middle neck mass
a: 1- congenital
- thyroglossal cyst
- dermoid cyst
- thymic tumor
a: 2- cx. Lymph adenopathy:
- inflammatory
- neoplastic( metastasis)
 a: 3- neoplasm:
-Benign:
-lipoma
-chondroma
-isthmus swelling
- malignant:
- thyroid ca.
a: 4- inflammations:
thyroiditis, infected
thyroglossal cyst
B.Lateral neck mass
B: 1- cong. :
lymphangioma
lat. Thyroglossal cyst
B: 2- developmental:
- branchial cyst
- laryngocoele
-pharyngeal pouch cyst
B: 3- swelling related to the gland :
-submandibulr
= sialadenitis
= stone
= tumor
- thyroid gland ------------------goitor
,tumor.
B: 4- parapharyngeal tumors
parotid tail, carotid body tumor
B : 5-soft tissue swelling (ludwig`s angina)
B: 6- cx. Lymphadinitis
-acute( URTI)
-chronic(tb,syph. AIDS)
B: 7- cx. Ln . Tumor
1-lymphoma
2-metastatic
B: 8- sternomastoid muscle tumor
B: 9 – cx. rib
Clinical evalutions
 HISTORY:
age =
chronicity=
associated symtoms=
concurrent illnesses & past h.=
drug use=
exposure to infections
Examinations
 GENERAL
 CHARECTERS
 ASSOCIATED SIGNS
INVESTIGATIONS
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LAB. :
- CBP, ESR ,B.FILM
-throat swab for c/s ,KLB
-tub.t
-serologic tests for HIV,CMV, EBV.
RAD: - CXR u/ss ,MRI,Ct scan ,isotop
Thyroid function tests
F.N.A( cyto, AFB, culture aerobic &anaerobic)
EXCISIONAL BIOPSY
Fine Needle Aspiration Biopsy
 Standard of diagnosis
 Indications
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Any neck mass that is not an obvious abscess
Persistence after a 2 week course of antibiotics
 Small gauge needle
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Reduces bleeding
Seeding of tumor – not a concern
 No contraindications (vascular ?)
EXCISIONAL BIOPSY
1. Present of signs& symptoms of
malignancy
2. Persist lymphadenopathy
3. DX. Remain in dout.
Thyroglossal Duct Cyst
 Most common congenital neck mass (70%)
 50% present before age 20
 Midline (90%).
 Usually just inferior to hyoid bone (65%)
 Painless unless infected.
 Elevates on swallowing/protrusion of tongue
 Treatment is surgical removal (Sis trunk) after
resolution of any infection
Thyroglossal Duct Cyst
Branchial Cleft Cysts
 Branchial cleft anomalies
 2nd cleft most common (95%) – tract medial to
cnXII between internal and external carotids
 Most common as smooth, fluctuant mass
underlying the SCM
 Skin erythema and tenderness if infected
 Treatment
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Initial control of infection
Surgical excision, including tract
Branchial Cleft Cysts
Lymphoma
 More common in children and young adults
 Up to 80% of children with Hodgkin’s have a neck mass
 Signs and symptoms
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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
Lymphoma
Vascular Tumors
 Lymphangiomas and hemangiomas
 Hemangiomas often resolve
spontaneously, while lymphangiomas
remain unchanged
 CT/MRI may help define extent of
disease
Vascular Tumors
 Treatment
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Lymphangioma – surgical excision for
easily accessible or lesions affecting vital
functions; recurrence is common
Hemangiomas – surgical excision reserved
for those with rapid growth involving vital
structures or associated thrombocytopenia
that fails medical therapy (steroids,
interferon)
Vascular Tumors
Cystic
hygroma
(hemangioma
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 Body Tumor