Adult Neck Masses

Justin Dumouchel

9/14/05

Anatomy

Anterior Triangle – middle of the neck, the sternocleidomastoid muscle and lower border of the mandible

-submental triangle-submandibular triangle

Posterior Triangle- sternocleidomastoid, the anterior border of the trapezius, and the middle third of the clavicle

Triangle Anatomy

Lymph Node Identification• Level 1 contains the submental and

submandibular 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.

Adults vs. Children

• Asymptomatic neck masses among adults older than 40 years old are considered malignant until proven otherwise.

• 80% of non-thyroid and non-salivary gland masses are neoplastic (80% of which are malignant)

• Children 90% of neck masses are benign

60 yo male smoker presents with a unilateral, asymmetric nodular neck mass. His local PCP gave him a 2 week trial of antibiotics without effect.

What should be done first?

• A – patient should be followed for an additional 2 weeks

• B – physical exam followed by FNA of the node

• C – open incisional biopsy

• D – schedule patient for modified neck dissection

Work up of Head and Neck Asymmetric, Unilateral “Nodal” mass

1) Physical exam and history

2) Fine Needle Aspiration

3) Imaging if FNA positive

4) Panendoscopy with guided biopsy based on location of nodal mass

5) Open biopsy with frozen sections if primary not found – neck dissection if warranted at that time

Indications for FNA

1) Progressively enlarging nodes

2) A single asymmetric node

3) A persistent nodal mass without antecedent active signs of infection

4) Actively infectious condition that do not respond to conventional antibiotics

Imaging techniques

Radionucleotide scanning

Sialography

Ultrasonography

Arteriography

CT and MRI imaging

PET – not advocated at this time

Why should imaging occur prior to endoscopic guided biopsies in

unknown neck mass?

1) Postoperative edema

2) Cost

3) To eliminate the need for endoscopy

Recommended biopsies for unknown primary tumor

• Nasopharynx• Tonsils – bilateral

tonsillectomy• Pyriform sinus• Hypopharynx• Postcricoid region• Base of the tongue

Head and Neck Tumors

Epithelial tumors - Squamous cell carcinoma (11,000 new/yr) - Adenocarcinoma - Salivary Gland - ThyroidMelanomaNeuroepithelial tumorsConnective Tissue tumors - lymphoma - sarcoma

Squamous cell carcinomaT1 > 2 cm, T2 2 – 4 cm

T3 > 4 cm T4 invasion of

antrum

N0 – no positive nodesN1 – single node < 3 cmN2a – single node 3 – 6 cmN2b – multiple homolateral nodes

< 6 cmN2c – multiple bilateral nodes < 6

cmN3 -- Nodes > 6 cm

M (distant metastasis)

Stages I - T1M0N0

II – T2N0M0 III – T3N0M0 -- T1-3,N1M0 IV - T1-3,N2-3M0 T1-3N0-3M1

SCC Treatment strategies

Known primary SCCChemotherapy – cisplatin and 5-FUStage I – II -> radiotherapy or surgeryStage III – IV -> combined radiotherapy and

surgeryUnknown primary SCC N1-N2a - surgery or radiotherapy > N2a - surgery and radiotherapy

The greatest morbidity following a radical neck dissection?

1) Lack of drainage of internal jugular vein

2) deficit of the sternocleidomastoid muscle

3) Accessory nerve deficit

4) Edema secondary to lymph node dissection

• RND -> excision of LN I – V with the addition of the SCM, ipsilateral IJV, and spinal accessory nerve

If neck biopsy occurs prior to definitive treatment which of the outcomes are worse with metastatic

cervical carcinoma?

• 1) wound necrosis

• 2) regional neck recurrence

• 3) distant metastasis

• 4) all of the above

Thyroid Carcinoma

15% of papillary carcinoma present with lymph node metastasis (80% of thyroid carcinoma)

Investigate mass initially with FNA (then +/- thyroid scan and +/- ultrasound)

Salivary Neoplasms

• Benign: usually asymptomatic (common)

• Malignant sx: pain, rapid growth, CN VII sxs, or skin fixation suggest malignancy

• Parotid most common and often benign

• Smaller glands are more likely malignant

• Definitive surgery should be performed at biopsy to prevent seeding of benign tumors.

Salivary Neoplasms

Benign• Pleomorphic adenoma – 65% of parotid tumors • Adenolymphoma (Warthin’s tumor) – 6 – 10% of

parotid tumors (frequently bilateral)

Malignant

Mucoepidermoid Carcinoma – most common salivary gland malignancy

50 yo female presents with a pulsatile, compressible mass that refills rapidly on the

release of pressure. Diagnosis?

Carotid body tumor – originate from small chemoreceptive and baroreceptive organs located at the adventitia of the common carotid artery bifurcation. (paragangliomas)

35 yo HIV+ patient presents with a tender neck node. When is it appropriate to biopsy a patient

with AIDS?

• 1) single rapidly enlarging node

• 2) a newly tender node (suspect TB or Nocardia)

• 3) node that has enlarged concomitant with a change in the systemic systems,

• 4) a single enlarged (> 3 cm) node in a chain of nodes

Thank you

Current Residence Borwell 548