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Central neck mass

1. Central Neck Mass Dr. Amanj Jalal Namq

2. Definition Mass: a lump or an aggregation of coherent material (soft tissue mass) Lump: an irregularly shaped mass or piece (breast lump) Swelling: an abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid Cyst: a swelling consisting of collection of fluid in a sac which is lined by epithelium or endothelium

3. Anatomy The neck is the transitional area between the base of the cranium superiorly and the clavicles inferiorly. The neck joins the head to the trunk and limbs, serving as a major conduit for structures passing between them.

4. Anatomic landmarks: Anteriorly: the neck starts from lower border of mandible to the upper border of the sternum (suprasternal notch) and clavicles.

5. Posteriorly: from external occipital protuberance to the spinous process of C7

6. Anatomy of the neck by triangles

7. Anterior triangle, more subdivided

8. Posterior triangle more subdivided:

9. Surface Anatomy

10. Lymph nodes of the head and neck The anatomy of these lymph nodes and the patterns of lymphatic drainage is important Head: Occipital: at the base of the skull Postauricular (mastoid): behind the ear, slightly anterior to the mastoid process Preauricular: in front of the ear Parotid: near the angle of the jaw Submandibular (submaxillary): midway between the angle of the jaw and the tip of the mandible Sublingual: near the midline, beneath the tongue Submental: in the midline, posterior to the tip of the mandible Neck (these lie in and the anterior or posterior triangles or under the sternocleidomastoid muscle) Anterior cervical chain: over and anterior to the sternocleidomastoid, in the anterior triangle Internal jugular chain: behind and largely covered by the sternocleidomastoid Posterior cervical spinal nerve chain: near the cervical vertebrae (located in the posterior area of the neck) Posterior superficial chain: along the anterior edge of the trapezius, in the posterior triangle Supraclavicular: just above the clavicle in the angle formed by the clavicle and sternocleidomastoid muscle

11. Surface Anatomy

12. Patient presented with neck lump, swelling or mass, what is your work up?

13. History Age: Neck masses in children and young adults are more commonly inflammatory than congenital, and rarely neoplastic. In adult, there is always suspension to be neoplastic (unless proven otherwisw ) Note: A ‘rule of 80’ provides a useful guide. In adults, 80% of non-thyroid neck masses are neoplastic, and 80% of these are malignant. A neck mass in a child, however, has a 90% probability of being benign.

14. * Cystic hygroma = cystic lymphangioma

15. History- Location Notes: A dermoid is cystic nature that contains an array of developmentally mature, solid tissues, e.g., skin, hair, sebum, sweat glands, teeth, thyroid tissue, etc. Ludwig’s angina is a type of severe cellulitis involving the floor of the mouth Delphian lymph node = prelaryngyeal / precricoid lymph node, which lies above the thyroid isthmus, anterior to the cricothyroid membrane and between the cricothyroid muscles Midline swellings

16. Lateral swellings

17. History- Duration Inflammatory disorders are usually acute in onset, and resolve within 6 weeks. Cervical lymphadenitis is often associated with recent upper tract infection. Congenital masses are often present from birth as small (asymptomatic) masses, which enlarge rapidly after mild upper respiratory tract infection. Metastatic carcinoma tends to have a short history of progressive enlargement. Note: Although congenital masses are more consistent in their locations, metastatic nodes follow a predictive pattern and help in identifying the primary malignancies. Transient post-prandial swelling in the submandibular or parotid area suggests salivary gland duct stenosis that may lead to obstruction. Bilateral diffuse tender parotid enlargement is most commonly mumps in children and sialosis in adults.

18. History Discharge: Suggest infection, mostly complicated congenital pathologies due to fistula or sinus formation with supper added infection (Abscess) Others: Family Hx: TB Social Hx: smoking, alcohol, and history of travel and contact

19. Physical examination General examination: JACOL Jaundice Anemia Cyanosis Edema Lymph nodes Vital signs: O2%, PR, RR, BP, Temperature Full head and neck examination The oral cavity and nasopharyngeal Mucosal surfaces, is helpful, especially when suspecting (* Full head and neck examination, including mucosal surfaces, is helpful, especially when suspecting malignancies.) Palpate the thyroid The lumps relation to muscles, trachea, and hyoid bone The location, mobility and consistency of a neck mass can often place it within a general etiological group – congenital, nodal/inflammatory, vascular, salivary or neoplastic. Look at the eyes

20. Fluid-filled masses- cysts and abscesses Vascular masses, e.g., aneurysm or vascular tumor Note: “irreducibility” is usually used to describe hernias (not that important for neck masses)

21. Do not forget to chick the abdomen !!!! Check the abdomen for a mass A cancer in the abdomen can drain to a lymph node in the neck For example, stomach cancer can metastasize to the neck, producing an enlarged Virchow’s node ( Troisier sign)

22. Neck mass features Congenital masses are generally soft, smooth and mobile, and may be tender when infected. Inflammatory adenopathy is tender, mobile mass Note: a high suspicion of inflammatory adenopathy with an otherwise negative examination may warrant a clinical trial of antibiotics and observation for up to 2 weeks, with close follow-up. Chronic inflammatory masses and lymphomas are often non-tender and rubbery and may be either mobile or feel like matted (coalesced) adenopathy (note: the lymph nodes become fibrotic?) In older age groups, the submandibular and parotid glands become ptotic and mimic neck lumps, and can cause concern to patients.

23. Features that raise suspicion of malignancy Voice change, Odynophagia Dysphagia Hemoptysis Previous radiation, especially with thyroid tumors. Note: for example, medical staff that are exposed to radiation due to their work, such as orthopedics and neurosurgeons) Oral lesions, recent trauma, globus sensation (a functional esophageal disorder characterized by a sensation of a lump, retained food bolus, or tightness in the throat that is not due to an underlying structural lesion, gastroesophageal reflux disease, mucosal abnormality, or an esophageal motility disorder) Referred ear pain, muffled or decreased hearing Constitutional symptoms (e.g., Night sweats, anorexia, weight loss) Unilateral nasal discharge or epistaxis Family history of cancer (e.g., lymphomas) and previous tumors (e.g., a patient with right thyroid cancer that had a hemithyroidectomy, and decades after their other lobe also gets cancer) Family history is also important for TB

24. Diagnostic tools Investigations: Full blood count Erythrocyte sedimentation rate (ESR). Throat swab: occasionally helpful, but must be sent immediately in the proper medium. Viral serology: Epstein–Barr virus, cytomegalovirus and toxoplasmosis. Thyroid function tests (T3, T4, TSH) and ultrasound in all cases of thyroid enlargement. Images: Ultrasonography is useful in differentiating solid from cystic masses. Chest X-ray in smokers with persistent neck lump. CT scan and MRI to determine the extent of the masses Fine needle aspiration biopsy (FNAB)  is helpful for the diagnosis of neck masses and any neck lump that is not an obvious abscess and persists following antibiotic therapy. A negative result may require a repeat FNAB, ultrasound-guided FNAB or even an open biopsy. FNAB is also called fine-needle aspiration cytology (FNAC), the latter to emphasize that any aspiration biopsy involves cytopathology, not histopathology. As it’s cytology, you only look at single cells; Cytology generally involves looking at a single cell type, while histology is the exam of an entire block of tissue. This may not always be reliable, and tissue biopsy may be needed. Getting a tissue biops y may be difficult as the neck has many vital structures In addition, open biopsy of any tumor mass may spread disease to deep neck tissues and could lead to an inoperable or fatal result. If needed, a Trucut biopsy or open biopsy can be done.

25. Treatment differ s according to the diagnosis

26. Characteristics of non-malignant neck lumps 1. Cystic hygroma (Lymphangiomas) It is a congenital lesion usually present within the first year of life . (post. Triangle) Usually remain unchanged into adulthood I t’ s a soft, cystic, multilocular, partially compressible and brilliantly transilluminant (a light is put against the mass in a dark room, and it lights up) and may present with pressure effects. CT or MRI may help define the extent of the neoplasm Treatment of lymphangiomas includes injection with picibanil (sclerosing agent) or excision for easily accessible lesions or those affecting vital functions.

27. Note (extra): [1] Picibanil (OK-432) is an inactivated preparation of a low-virulence strain of group A S treptococcus pyogenes of human origin pretreated with benzylpenicillin G and heat preparation and is an effective sclerosing agent. The mechanism of action is speculated to be that it induces an inflammatory response at the site of infection that leads to sclerosis and occlusion of the sites of lymphatic leakage from lymphatic malformations. Alternatively, the inflammation it induces could also lead to increased resorption and/or drainage of excessive lymphatic fluid by opening new channels. The two mechanisms may be mutually causing the shrinkage of lymphatic malformations. Therefore, it’s important that local inflammation and fever occurs after injection to achieve clinical improvement.

28. 2. Haemangiomas Often appear bluish and are compressible. CT or MRI may help define the extent of the neoplasm, especially intrathoracic. Treatment : (depend on site, size and severity) most often resolve spontaneously within the first decade. surgical treatment is reserved for lesions with rapid growth involving vital structures, which fail medical therapy (cs, laser or oral propranolol in infantile type).

29. 3. Branchial cleft cysts Reminant of branchial cleft (2 nd ). Most commonly occur in the second or third decades! Pain +/- (severe throbbing pain) Usually presents as a smooth, fluctuant nontender (tender) , nontransluminal mass mobile forwards and downwards, underlying the anterior border of the sternomastoid muscle. Branchial fistula or sinus ! Primary treatment is with control of infection by antibiotics, followed by surgical excision.

30. 4. Thyroglossal duct cyst This is a common congenital midline neck mass. Sometimes at the lateral edge of the thyroid cartilage. Pain and tenderness +/- Can be moved transversally but can not be moved vertically Elevates on protrusion of the tongue (pathognomonic) Note: This almost pathognomonic sign, where it moves upwards with swallowing or when the patient protrudes their tongue, is because the thyroglossal duct is also attached to the hyoid bone and the peritracheal fascia. Treatment is with initial control of infection with antibiotics, followed by surgical excision including the mid-portion of the body of the hyoid bone (Sistrunk’s procedure).(note: this procedure involves excision of the cyst, the middle part of the hyoid bone, and the surrounding tissue around the thyroglossal tract) Occasionally, these lesions become infected and resolve, or persist following surgery as a thyroglossal fistula Note: A thyroglossal duct cyst may rupture unexpectedly, resulting in a draining sinus known as a thyroglossal fistula. Thyroglossal fistula can develop when the removal of the cyst has not been fully completed

31. 5. Lipoma Lipomas are the most common benign soft tissue neoplasm in the neck. They are poorly defined, soft masses usually after the fourth decade. They are usually asymptomatic, soft to feel and deep to the skin Note: slippery (pathognomonic) (??) FNAC or MRI Scan can confirm the diagnosis. Surgery is indicated when the lump is increasing in size, cosmesis, or when there is doubt about the accuracy of diagnosis. Note: A characteristic "slippage sign" may be elicited by gently sliding the fingers off the edge of the tumor. The tumor will be felt to slip out from under, as opposed to a sebaceous cyst or an abscess that is tethered by surrounding induration. The overlying skin is typically normal.

32. 6. Sebaceous cysts Sebaceous cysts form inside oil glands inside the skin. These are common masses occurring often in older people but can occur at any age. They are slow growing, but sometimes fluctuant and painful when infected. Diagnosis is made clinically; the skin overlying the mass is adherent and a punctum is often identified (note: there’s a punctum since this is a gland) Excisional biopsy confirms the diagnosis. (entire lesion is removed and sent for biopsy)

33. 7. Cervical lymphadenopathy Acute lymphadenitis tender swelling Antibiotic trial, Less acute inflammatory nodes generally regress in size over 2–6 weeks. If the lesion does not respond! biopsy

34. 8. TB cervical lymphadenitis Upper and middle deep cervical LN Onset: gradually Pain: +/- Systemic symptoms unusual in young (occurs with Abscess (painful, increase size, and skin discoloration) Mass: indistinct, firm, matted, fluctuate! Temperature! (Cold abscess)

35. Tuberculous lymphadenitis is popularly known as collar stud abscess, due to its proximity to the collar bone and its superficial resemblance to a collar stud (a collar stud is an object like a button, used to fasten old-fashioned collars to shirts

36. Treatment with anti TB (6-9 months) Rifampicin Et ha mbutol INH Pyrazinamide

37. 9. Carotid body tumour Rare tumour of chemoreceptors (40-60 years) ( Chemodectoma ) Slow-growing painless some time pulsating lump may be bilateral. Side to side movement Symptoms of transient cerebral ischemia! Potato tumours (hard, non tender) Palpation may induce vasovagal attack Biopsy is contraindicated MRI angiography is the investigation of choice. Surgical removal is based on patient factors presenting symptoms.

38. 10. Pharyngeal pouch diverticulum of the pharynx through the gap between the horizontal fibres of the cricopharyngeus muscle below and the lowermost oblique fibres of the inferior constrictor muscle above. history of halitosis regurgitation of froth and food. There is no bile or acid taste to it. Pressure on the swelling causes gurgling sounds and regurgitation Treatment: cricopharyngeal myotomy

39. 11. Ludwing’s angina Rare but serious connective tissue infection of the floor of the mouth Note: An emergency; can cause suffocation Ludwig's angina (angina means choke) refers to the feeling of strangling and choking, secondary to obstruction of the airway, which is the most serious potential complication of this condition. Mostly due to dental infections Sings of inflammation present Treatment: drainage of pus + antibiotic to cover aerobes with anaerobes

40. 12. Thyroid masses Thyroid neoplasms are a common cause of anterior compartment neck masses in all age groups, with a female predominance, and are mostly benign. Fine needle aspiration of thyroid masses has become the standard of care and ultrasound may show whether the mass cystic. Unsatisfactory aspirates should be repeated, and negative aspirates should be followed up with a repeat FNAC and examination in 3 months’ time.

41. Characteristics of malignant neck lumps 1. LYMPHOMAS Painless lump, nontender smooth and discrete Slow growing Patient Presented with malaise, wt. loss, pallor. Fever, rigor and hepatosplenomegaly Mediastinal mass (SVC syndrome) Abdomen pressure on IVC may cause bilateral leg edema other lymph nodes in the axilla, groin and abdomen should examined Treatment: according to stage (radiosensitive) Note: surgery is used for diagnostic purposes, not for treatment

42. 2. METASTATIC LYMPH NODES Upper cervical lymph nodes (upper aerodigestive tract). Accessory chain of nodes in the posterior triangle (Nasopharyngeal malignancies). In many cases (Occult primary) most common sites are tonsil, base of tongue, nasopharynx and pyriform sinus. Virchow's LN ( toisier ’s sign) abd . And thoracic malignancies Painless, nontender, and hard masses Work up: Search for primary and deal with it