Ent clinical rotation presentation neck masses by xavier

Wednesday, May 3, 2023Neck masses by RUTAYISIRE François Xavier

1ENT CLINICAL ROTATION PRESENTATION

TOPIC: MANAGEMENT OF NECK MASSES

PRESENTED BY: RUTAYISIRE François Xavier

LEVEL 5(DOC III)MEDICAL STUDENT AT UR.

November 30th 2016


2A neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles.

Defi

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Definition

Definition


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The location of the mass can focus the differential.

Familiarity with neck anatomy is critical for diagnosis and management of disease processes affecting this region.

The neck is traditionally divided into the central and the lateral necks, with the lateral neck further subdivided into anterior and posterior triangles


The anterior triangle is delineated by :1. The anterior border of the SCM laterally, 2. The midline medially, 3. The lower border of the mandible superiorly.

The SCM divides each side of the neck into two major triangles, anterior and posterior.


5 The borders of the posterior triangles are : 1. The posterior border of the SCM anteriorly,2. The clavicle inferiorly, 3. The anterior border of the trapezius muscle posteriorly.


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The thyroid gland : is usually palpable in the midline below the thyroid cartilage. The parotid glands : are located in the preauricular area on each side in the lateral neck. The tail of each parotid gland extends below the angle of the mandible, inferior to the earlobe.


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Submandibular glands : are located within a triangle bounded by …. the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and the body of the mandible. Lymph nodes : are located throughout the head and neck region .


FIGURE 2. Lymph node groups with the most likely sites of the primary lesion.


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The evaluation of any neck mass begins with a careful HISTORY . The history should be taken with the differential diagnosis in mind because directed questions can narrow down the diagnostic possibilities and focus subsequent investigations. For example, in younger patients, one would tend to look for congenital lesions, whereas in older adults, the first concern would always be neoplasia.


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Differential diagnosis

It is helpful to consider the differential diagnosis in three broad categories:

●Congenital●Inflammatory●Neoplastic


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RULE OF SEVEN....

1. Mass present for seven days is inflammatory.2. Mass present for seven months is neoplastic.3. Mass present for seven years is congenital.


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the differential diagnosis


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Additionally, patterns of lymph node drainage can identify areas of concern when metastatic disease is suspected.


15The localization of lymph nodes in the neck


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CONGENITAL NECK MASS

Usually present at birth, but may present at any age.Most common noninflammatory neck mass in

children.Malgnancy in adult until proven otherwise

Cystic lesions such as branchial cleft cysts can present in adulthood, and should be investigated to ensure malignancy is not present.

Carcinomas of the tonsil, tongue base, and thyroid may all present as cystic neck masses.


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Congenital/developmental masses – Midline&Lateral

Thyroglossal cysts Cystic hygromasBranchial cysts Plunging ranulasDermoid cysts


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TGDC

Midline anterior neck.Rounded with a diameter of 2-4cmDiagnosed in childhood, but up to 40 percent

may present after age 20 Asymptomatic except when infected by URTIMove with tongue protrusionRarely carcinoma develop in cyst.


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Endoderm of the floor of mouth between the 1st and 2nd archs.

Descends as a bilobed diverticulum from the foramen cecum around the 4th week to rest by the 7-8th week.

EMBRYOLOGY


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Management of TGDC

Excision to confirm the diagnosis and to prevent future infections.

The Sistrunk operation is the procedure of choice.

Thyroid carcinoma can be present in (1 to 2%) of thyroglossal duct cysts,

All thyroglossal duct cysts and tracts should undergo a careful histologic examination


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Cystic hygromas (lymphangiomas)

Cystic hygromas are present as soft, fluctuant and transilluminable masses just under the skin.

Nearly all present by the age of 2 to 3 years, with 60% occurring in the head and neck region (usually in the posterior triangle) and most presenting at birth.

They are multiloculated and painless. Ultrasound is useful to confirm the diagnosis

and CT scanning is essential if surgery is contemplated.

Ectopic Thyroid

90% are lingualSymptoms are of base of tongue obstruction,

dysphagiaSurgical Excision

Plunging Ranula

A ranula is a mucocele or retention cyst arising from an obstruction in the sublingual glands in the floor of mouth.

Simple ranula- unilateral oral cavity cystic lesion

Painless and slow-growing. They are most often located in the submentum.When they extend through the mylohyoid

muscle into the neck they are referred to as "plunging ranula".


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Management

Plunging ranula- pierce the mylohyoid to present as a paramedian or lateral neck mass.

CT scan/MRITreatment is intraoral excision to include the

sublingual gland of origin.


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Branchial cleft cyst

Almost 20 percent of pediatric neck masses.Present in late childhood or early adulthood when a

previously unrecognized cyst becomes infected. Only a very small percentage first present in

adulthood. Relatively consistent in their location in the neck,

anterior to the SCM. Painless swelling�Young adults� �M= F ratioUnilateral, 75% on left side


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Embryology

At the 4th week of embryonic life, the development of 4 branchial (or pharyngeal) clefts results in 5 branchial (or pharyngeal) arches,

The second arch grows caudally and, ultimately, covers the third and fourth arches.

The buried clefts become ectoderm-lined cavities, which normally involute around week 7 of development. If a portion of the cleft fails to involute completely, the entrapped remnant forms an epithelium-lined cyst with or without a sinus tract to the overlying skin.

Pathophysiology


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Branchial cleft cyst


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First branchial cleft cysts

Account for less than 1 percent of branchial cleft anomalies.They typically appear on the face near the auricle.Divided into types I and IIType I first branchial cleft cysts are duplication anomalies of

the external auditory canal and are of ectodermal origin.They pass through the parotid gland often in close proximity

to the facial nerve.Type II branchial cleft cysts are more common and typically

present below the angle of the mandible.They contain both ectoderm and mesoderm and pass through

the parotid gland medial or lateral to the facial nerve and end either inferior to the external auditory canal or at the bony cartilaginous junction of the external auditory canal.


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Second Branchial Cleft Cysts

Most Common (90%) branchial anomalyPainless, fluctuant mass in anterior triangleInferior-middle 2/3 junction of SCM, deep to

platysma, lateral to IX, X, XII, between the internal and external carotid and terminate in the tonsillar fossa

Surgical treatment may include tonsillectomy

Third Branchial Cleft Cysts

Rare (<2%)Similar external presentation to 2nd BCCCourses cephalad to the superior laryngeal

nerve through the thyrohyoid membrane, medial to IX, lateral to X, XII, posterior to internal carotid

Surgical approach must visualize recurrent layngeal nerves- Thyoidectomy incision

Fourth Branchial Cleft Cysts

Courses from pyriform sinus apex caudal to superior laryngeal nerve, to emerge near the cricothryoid joint, and descend superficial to the recurrent laryngeal nerve.


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Management

Management of branchial cleft cysts begins with controlling infection, if present.

Once the infection has resolved, the mass is usually excised to prevent future problems

Thymic Cyst

Thymus develop from 3rd pharyngeal pouch and descend to neck to the mediastinum.

Thymic remnants may persist anywhere in its path from angle mandible to midline of neck.

Swelling either cystic or solid.Can occur in children or adults by presents of

anterior neck mass and deep to middle SCM.Rare conditionTx: Surgical excision + sternotomy if extend

into mediastinum.


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Sublingual Dermoid Cyst

Midline submental swelling but does NOT move on protrusion of tongue.

Can be arises from floor of mouth and need to be diffrentiated with ranula.

Tx: Surgical excision

Teratoid Cysts and Teratomas

All three germ cell layers- Endoderm, mesoderm and ectoderm.

Larger midline masses, present earlier in life.20% associated maternal polyhydramniosUnlike adult teratomas, they rarely

demonstrate malignant degeneration.Surgical excision.


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Infective and inflammatory masses

Infectious inflammatory disorders - Reactive viral lymphadenopathy - Bacterial lymphadenopathy - Parasitic lymphadenopathy

Noninfectious inflammatory disorders


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Mycobacterial lymphadenitis

Mycobacterial lymphadenitis should be suspected in an acute lymphadenitis, with only mild tenderness and a partial response to antibiotics.

Other rare granulomatous causes of adenopathy include cat scratch disease and actinomycosis.


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HIV infection

Cervical lymphadenopathy is very common in patients with HIV infection.

Lymphadenopathy syndrome is a mild form of HIV disease that represents one of the initial stages of the infection.

Patients can remain stable for months to years, with little in the way of symptoms.

This diagnosis should be considered in any adult with persistent generalised lymphadenopathy and the relevant risk factors.


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Acute sialadenitis

Acute infection of the salivary glands can be bacterial or viral in origin.

Bacterial sialadenitis occurs more frequently in the parotid glands, is more common in the elderly and is associated with reduced salivary flow from dehydration.


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Management

Treatment is with broad-spectrum antibiotics covering S. aureus, the most common pathogen causing infection of the salivary glands, in addition to supportive measures (rehydration, analgesics and gland massage to encourage salivary flow).

Appropriate antibiotics include flucloxacillin, cephalexin and clindamycin.

Surgical drainage may be required if an abscess develops.


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Viral sialadenitis

Most commonly due to the mumps virus, which typically affects the parotid glands bilaterally.

The mumps virus most often affects children, with peak incidence at ages 4 to 6 years.

Other causes include coxsackievirus, cytomegalovirus and HIV


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Thyroiditis

The most common inflammatory goitre is Hashimoto’s thyroiditis.

Autoantibodies against thyroid peroxidase are produced, resulting in lymphocytic infiltration of the thyroid and eventually a goitre, which is typically firm and rubbery.

Management by an endocrinologist is usually necessary because of the initial hyperthyroidism and subsequent hypothyroidism.

Occasionally surgery is required for obstructive symptoms.


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NEOPLASTIC DISORDERS

Metastatic head and neck carcinomaSquamous cell carcinomaThyroid CancerSalivary gland malignancyParagangliomasSchwannomaLymphomaLipoma.


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SCC is the most common cause of a malignant neck lump.

Metastatic SCC most commonly arises from the mucosa of the upper aerodigestive tract (oral cavity, nasopharynx, oropharynx and laryngopharynx).

Cutaneous malignancies (SCC and melanoma) may also metastasise to the parotid gland or lateral cervical lymph nodes, sometimes years after the primary tumour was excised.

Squamous cell carcinoma


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Lymphoma

The nodes are typically ‘rubbery’ in consistency. Associated symptoms include night sweats, lethargy and weight loss.

Lymphoma is the most common cause of a malignant neck lump in children and should therefore, despite being rare, be considered in the differential diagnosis of any progressive or persistent childhood lymphadenopathy.

FNAB and CT scan are indicated, with referral to a haematologist if cytology is suggestive of lymphoma


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Adenocarcinoma

Adenocarcinoma is a type of cancer that forms in mucus-secreting glands throughout the body.

Metastatic adenocarcinoma to the upper cervical lymph nodes may originate from the salivary glands or sinonasal cavity.

Metastatic adenocarcinoma in the lower neck may arise from a site below the clavicles (e.g. lung, oesophagus or stomach).

Virchow’s node (also referred to as Troisier’s sign) refers to metastatic adenocarcinoma occurring in the left supraclavicular fossa and usually arising from the stomach


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Thyroid cancer

Most thyroid cancers present clinically with a palpable thyroid nodule, which is often asymptomatic. About half of thyroid cancers are initially noticed by the patient, whereas the remainder are detected during routine physical examination, by chance on imaging studies often for unrelated medical conditions or during surgery for benign thyroid disease.

Occasionally thyroid cancer can present with a metastatic neck node, and the diagnosis is confirmed on FNAB.


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Management

When thyroid cancer is suspected or demonstrated on FNAB, prompt referral to a ENT surgeon is warranted.

Total thyroidectomy and adjuvant iodine ablation therapy is indicated for most patients diagnosed with thyroid cancer.


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Salivary gland malignancy

Salivary gland cancers include adenocarcinoma and metastatic cutaneous SCC.

Symptoms and signs that suggest malignancy include pain, rapid growth, a hard mass, fixity to the skin or mandible and facial nerve palsy. FNAB and CT/MRI scanning are essential to assess the extent of disease and to plan surgery.

High-grade salivary gland malignancy often requires neck dissection and postoperative radiotherapy.


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Carotid body tumours

Carotid body tumours are rare benign tumours of the carotid body neural plexus.

They usually present as a painless pulsatile mass at the level of the carotid bifurcation, and typically can be moved side to side but not vertically.

The tumours are extremely vascular, and are diagnosed using a combination of CT scan, MRI, magnetic resonance angiography and carotid doppler scanning.

Following comprehensive assessment, surgery is usually performed by a head and neck surgeon and a vascular surgeon.

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Ent clinical rotation presentation neck masses by xavier

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