Transcript Neck Mass Presentation D Amottx

Neck Lumps
Dr Deborah Amott
ENT Surgeon
[email protected]
Core Presentations
By the end of this year, you should be able to perform a
competent medical interview, physical examination and
suggest a basic investigational plan for a patient presenting
with this symptom.
An accurate diagnosis is:
90% History
9% Examination
1% Investigations
Getting the Words Right
Clinical Assessment =
History + Examination
Diagnosis =
Clinical Assessment + Investigation/s
Management = Diagnosis + Treatment
Lumps and Bumps: The Mnemonic
She Cuts The Fish PERfectly
Three Ss
Site - describe location briefly
Size - use your hand and fingers to
estimate if you do not have a ruler with
you
Surface/overlying skin
Three Fs
Fluctuance - ?fluid-filled cyst
Fixation - ?is it fixed to the underlying
tissue or to the overlying skin
Fields - draining lymph glands in the
area
Three Cs
Colour
Contour - is the lump well-defined or
irregular
Consistency - ?soft/firm/hard
Finally, remember to check for
whether the lump is:
Pulsatile (Is it an aneurysm?)
Expansile (Is it an aneurysm?)
Reducible (Is it a hernia?)
Three Ts
Tenderness
Temperature - Is it hot/inflamed?
Transilluminable
Age of Patient +
Location of Lump +
Acuity of Symptoms
= Likely Diagnosis
Neck: Triangles
Normal Structures Present?
Neck Mass: DDx
Inflammatory/Infectious:

Acute: bacterial lymphadenitis,
glandular fever, reactive
lymphadenopathy due to URTI.

Subacute/chronic lymphadenitis:
TB/atypical mycobacterium, cat
scratch disease

Neck abscesses: traumatic, foreign
body, dental abscesses

Salivary: sialodenosis/itis/lithiasis,
Sjogren’s syndrome
Granulomatous disease:

Sarcoidosis, Kimura’s Disease etc
Neoplasms

Lymph nodes: primary
(lymphoma/leukaemia) vs. metastatic
(SCC, melanoma, Merkel Cell
carcinoma, salivary gland, thyroid,
intra-abdominal or thoracic
malignancy)

Salivary Gland

Sarcoma

Thyroid: adenoma vs. carcinoma

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Nerve derived: neuroma,
neurofibroma, schwannoma, sarcomas
Paraglanglioma (benign vs. malignant)
Neck Mass: DDx
Lymphovascular malformations
 Haemangioma
 Lymphagioma
 Cystic hygroma
 AVMs
Congenital abnormalities
 Ectopic thyroid gland
 Branchial cleft cyst
 Dermoid
 Thyroglossal duct cyst
Thyroid
• Multinodular or diffuse
enlargement
Other:
• Mediastinal masses with
neck extension
 Histiocytosis
 Castleman’s disease
 Gout/psuedogout
ad infinitum….
Ask 4 Questions…
 What is the most likely diagnosis?
 What is the most IMPORTANT diagnosis?
 Could this be life-threatening?
 What information do I need to confirm my
diagnosis?
 What’s my time frame?
Context of this Symptom
 Symptom itself:

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
Acuity
Duration
Severity
Fixed/Variability
Progression
Triggers/Relievers
 Associated features: what
else is changing?




Local, adjacent structures
Regional
Distant organ dysfunction
Systemic symptoms
 Patient:

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Demographics: age, sex,
race, ethnicity
Lifestyle: profession,
hobbies, smoking, alcohol,
other drugs, other
carcinogens, diet.
Immune status:
Immunosuppressed/Atopic/A
utoimmune disease
Comorbidities, previous
medical conditions or
treatment.
Environment: season,
latitude,
humidity/temperature,
recent events.
General Pathological Processes
VINDICATE
V-vascular
I-infectious/inflammatory
N-neoplasia
D-drugs
I-idiopathic
C-congenital
A-anoxia/acid-base imbalance/auto-immune
T-trauma/toxins
E-ethyl alcohol, endocrine
Genetic: too much vs. too little of an otherwise good
thing
Neck Lumps: Examination
 Examine the lump
 Examine the rest of the neck
 Lymph nodes, Parotid, Thyroid, Vessels
 Full ENT examination (including flexible
nasendoscopy)
 Skin
Top 3?
VINDICATE
V-vascular
I-infectious/inflammatory
N-neoplasia
D-drugs
I-idiopathic
C-congenital
A-anoxia/acid base
imbalance/auto immune
T-trauma/toxins
E-ethyl alcohol, endocrine
Genetic
Top 3
Infection
Infection
Infection
Infection
Congenital: lymphovascular
malformation, ectopic thyroid,
thyroglossal duct cyst, branchial
cleft cyst
Neoplasm: leukaemia/lymphoma
Top 3?
VINDICATE
V-vascular
I-infectious/inflammatory
N-neoplasia
D-drugs
I-idiopathic
C-congenital
A-anoxia/acid base
imbalance/auto immune
T-trauma/toxins
E-ethyl alcohol, endocrine
Genetic
Top 3
Infectious/Inflammatory
Neoplasia
Congenital
Top 3?
VINDICATE
V-vascular
I-infectious/inflammatory
N-neoplasia
D-drugs
I-idiopathic
C-congenital
A-anoxia/acid base
imbalance/auto immune
T-trauma/toxins
E-ethyl alcohol, endocrine
Genetic
Top 3
Infectious
Neoplasia
Aerodigestive tract,
skin, salivary, thyroid
Other
Top 3?
VINDICATE
V-vascular
I-infectious/inflammatory
N-neoplasia
D-drugs
I-idiopathic
C-congenital
A-anoxia/acid base
imbalance/auto immune
T-trauma/toxins
E-ethyl alcohol, endocrine
Genetic
Top 3
Neoplasia
Vascular
Infectious/Inflammatory
Investigation
 Know the question you want to answer.
 Only order an investigation if the result will affect your
management
 A proper initial clinical assessment and then repeated
thorough clinical assessment is always better than
multiple non-targeted tests.
 Recruit help
Investigations
Repeated clinical assessment is often the most
appropriate ‘investigation’.
Blood tests
Microbiology:
bacteria, fungal, viral
Biopsies:
FNA, incisional, excisional
Imaging:
plain XRs, US, CTs, MRI, PET, other (SPECT, nuclear medicine etc).
Other:
resp function tests, endoscopy, oximetry, ABGS etc.
Operations:
diagnostic endoscopy, open operations
Imaging
 Plain XRs
 Ultrasound
 Computed Tomography
 Magnetic Resonance Imaging
 Positron Emission Tomography
 Nuclear Medicine Scans
 The weird and wonderful
Biopsy Options
 Fine needle aspiration
 Incisional: ‘wide needle/core’, punch, shave, scalpel
 Excisional biopsy
 Wide local excision (“Halsteadian”, “en bloc”, “R0
resection”)
Treatment
 Behavioural: avoid triggers, diet, exercise, sleep,
environmental modification, mood management
 Non-pharmacological treatments: hygiene measures,
moisturisers, saline rinsing, dietary supplements etc
 Pharmacologic: topical, enteral, transcutaneous, injections
 Interventional
 Minimal: endoscopic, angiography, etc
 Maximal: open surgery, radiation etc
What’s the Cost-Benefit ratio?
ENT Handbook
References