Management of neck mases
-
Upload
dr-alihussein-kassam -
Category
Healthcare
-
view
455 -
download
0
Transcript of Management of neck mases
![Page 1: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/1.jpg)
An Approach to Patients with a Neck Mass
By Dr Alihussein kassamIntern doctor
Mnazi mmoja hospital,zanzibar
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 1
![Page 2: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/2.jpg)
Introduction
• Common clinical finding• All age groups• Very complex differential diagnosis• Systematic approach essential
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 2
![Page 3: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/3.jpg)
What will one think of?
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 3
![Page 4: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/4.jpg)
Anatomical Considerations• Prominent landmarks
copywrite@ Dr Alihussein KassamWednesday, May 3, 2023 4
![Page 5: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/5.jpg)
General Considerations
• Patient age– Pediatric (0 – 15 years): 90% benign– Young adult (16 – 40 years): similar to pediatric– Late adult (>40 years): “rule out CANCER”
• Location– Congenital masses: consistent in location– Metastatic masses: key to primary lesion
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 5
![Page 6: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/6.jpg)
Metastasis Location according to Various Primary Lesions
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 6
![Page 7: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/7.jpg)
Diagnostic Steps
• History
• Physical Examination
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 7
![Page 8: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/8.jpg)
Empirical Antibiotics
• Inflammatory mass suspected• Two week trial of antibiotics• Follow-up for further investigation
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 8
![Page 9: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/9.jpg)
Diagnostic Tests
• Fine needle aspiration biopsy (FNAB)
• Computed tomography (CT)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 9
![Page 10: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/10.jpg)
Fine Needle Aspiration Biopsy
• Standard of diagnosis
• Indications
• Small gauge needle
• No contraindications (vascular ?)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 10
![Page 11: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/11.jpg)
Fine Needle Aspiration Biopsy
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 11
![Page 12: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/12.jpg)
Computed Tomography
• Distinguish cystic from solid• Extent of lesion• Vascularity (with contrast)• Detection of unknown primary (metastatic)• Pathologic node (lucent, >1.5cm, loss of shape)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 12
![Page 13: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/13.jpg)
Ultrasonography
Role of U/S is limited,
“Why do an ultrasound if you can palpate?”
Dr Naufal kassim
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 13
![Page 14: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/14.jpg)
Nodal Mass Workup in the Adult
• Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise
• Asymptomatic cervical mass – 12% of cancer• ~ 80% of these are SCCa
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 14
![Page 15: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/15.jpg)
Metastatic neck disease
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 15
![Page 16: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/16.jpg)
Metastatic neck disease
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 16
![Page 17: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/17.jpg)
Metastatic neck disease
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 17
![Page 18: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/18.jpg)
Primary Tumors
• Thyroid mass• Lymphoma• Salivary tumors• Lipoma
• Carotid body and glomus tumors
• Neurogenic tumors
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 18
![Page 19: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/19.jpg)
Thyroid Masses
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 19
![Page 20: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/20.jpg)
•Do all thyroids with a pathology enlarge?
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 20
![Page 21: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/21.jpg)
Lymphoma
• More common in children and young adults• Up to 80% of children with Hodgkin’s have a neck mass• Signs and symptoms– Lateral neck mass only (discrete, rubbery, nontender)– Fever– Hepatosplenomegaly– Diffuse adenopathy
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 21
![Page 22: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/22.jpg)
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
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 22
![Page 23: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/23.jpg)
Lymphoma
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 23
![Page 24: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/24.jpg)
Salivary Gland Tumors
• Enlarging mass anterior/inferior to ear or at the mandible angle is suspect
• Benign – Asymptomatic except for mass
• Malignant– Rapid growth, skin fixation, cranial nerve palsies
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 24
![Page 25: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/25.jpg)
Salivary Gland Tumors
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 25
![Page 26: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/26.jpg)
Carotid Body Tumor
Rare in childrenPulsatile, compressible massMobile medial/lateral not superior/inferiorClinical diagnosis, confirmed by angiogram or CTTreatment
Irradiation or close observation in the elderlySurgical resection for small tumors in young patientsHypotensive anesthesiaPreoperative measurement of catecholamines
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 26
![Page 27: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/27.jpg)
Carotid Body Tumor
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 27
![Page 28: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/28.jpg)
Lipoma
• Soft, ill-defined mass• Usually >35 years of age• Asymptomatic• Clinical diagnosis – confirmed by excision
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 28
![Page 29: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/29.jpg)
Lipoma
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 29
![Page 30: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/30.jpg)
Congenital and Developmental Mass• Epidermal and sebaceous cysts• Branchial cleft cysts• Thyroglossal duct cyst• Vascular tumors
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 30
![Page 31: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/31.jpg)
Epidermal and Sebaceous Cysts
• Most common congenital/developmental mass• Older age groups• Clinical diagnosis– Elevation and movement of overlying skin– Skin dimple or pore
• Excisional biopsy confirms
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 31
![Page 32: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/32.jpg)
Epidermal and Sebaceous Cysts
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 32
![Page 33: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/33.jpg)
Branchial Cleft Cysts
• Branchial cleft anomalies
• Present in older children or young adults often following URI
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 33
![Page 34: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/34.jpg)
Branchial Cleft Cysts
• Most common as smooth, fluctuant mass underlying the SCM
• Skin erythema and tenderness if infected• Treatment– Initial control of infection– Surgical excision, including tract
• May necessitate a total parotidectomy
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 34
![Page 35: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/35.jpg)
Branchial Cleft Cysts
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 35
![Page 36: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/36.jpg)
Thyroglossal Cyst
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 36
![Page 37: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/37.jpg)
Thyroglossal cyst
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 37
![Page 38: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/38.jpg)
Vascular Tumors
• Lymphangiomas and hemangiomas• Usually within 1st year of life• Hemangiomas often resolve spontaneously, while
lymphangiomas remain unchanged• CT/MRI may help define extent of disease
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 38
![Page 39: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/39.jpg)
Vascular Tumors (lymphangioma)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 39
![Page 40: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/40.jpg)
Vascular Tumors (hemangioma)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 40
![Page 41: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/41.jpg)
Vascular Tumors
• Treatment– 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)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 41
![Page 42: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/42.jpg)
Inflammatory Disorders
• Lymphadenitis• Granulomatous lymphadenitis
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 42
![Page 43: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/43.jpg)
Lymphadenitis
• Very common, especially within 1st decade• Tender node with signs of systemic infection• Directed antibiotic therapy with follow-up
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 43
![Page 44: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/44.jpg)
Lymphadenopathy
• Equivocal or suspicious FNAB in the pediatric nodal mass requires open excisional biopsy to rule out malignant or granulomatous disease
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 44
![Page 45: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/45.jpg)
Granulomatous lymphadenitis
• Infection develops over weeks to months• Minimal systemic complaints or findings• Common etiologies– TB, atypical TB, cat-scratch fever, actinomycosis,
sarcoidosis• Firm, relatively fixed node with injection of skin
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 45
![Page 46: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/46.jpg)
Granulomatous lymphadenitis• Typical M. tuberculosis– Usually responds to anti-TB medications– May require incisional biopsy for further workup– Chest X-ray ? Important?– Skin test?
• Symptoms– Low grade fever– Night sweats– >10% weight loss
• Signs– Persistence fistula following I & D
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 46
![Page 47: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/47.jpg)
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 47
![Page 48: Management of neck mases](https://reader036.fdocuments.net/reader036/viewer/2022062316/58791f5c1a28abf13a8b6b99/html5/thumbnails/48.jpg)
Summary
• Extensive differential diagnosis• Age of patient is important• Accurate history and complete exam essential• FNAB – invaluable diagnostic tool• Possibility for malignancy in any age group• Close follow-up and aggressive approach is best for
favorable outcomes
Wednesday, May 3, 2023 copywrite@ Dr Alihussein Kassam 48