Approach to a Neck Mass.

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1 Approach to a Neck Mass

2 Objectives Develop a Diagnostic Approach Review Differential Diagnosis
Case-Based Review

3 History – Important Points
Mass itself: Duration, ? Size or character change since noticed Associated symptoms: Pain, sensory loss, epistaxis, dysphagia, hoarseness, hemoptysis, cold/heat intolerance, hearing change… Social history: Smoking, chewing tobacco, alcohol Past medical history Radiation*, skin cancer/lesion Family history *

4 Physical Examination Take the time to be thorough Inspection:
Exterior scalp, face, ear oropharnyx, hypopharnyx, larynx, nasal passage External Ear Flexible fiberoptic endoscopy Palpation -- External & Bimanual Mass, thyroid, lymph node levels, oropharnyx, salivary glands Relation to swallowing/tongue protrusion

5 Fine Needle Aspiration
Often the first diagnostic test Simple and highly sensitive No longer felt to risk spread of tumor Technically demanding sometimes * Don’t forget US guidance can be helpful Cytopathologist is key

6 Lab Tests & Imaging Play a smaller role than usual Blood work??
C.T. scanning Large/complicated mass ? Remote primary

7 Differential Diagnosis Simplified
Congenital Lesions * Salivary Gland Lesions * Thyroid Gland Lesions * Lymph Nodes *

8 Triangles of the Neck Anterior Posterior
Submandibular Submental Carotid Posterior

9 Triangles of the Neck Anterior Posterior
Submandibular Submandibular gland Submental Dermoid, ranula Carotid Branchial cleft cyst, Carotid Body Tumour Posterior Lipoma, Neurogenic tumor * Lymph node lesions can be anywhere *

10 Lymph Nodes Inflammatory Lymphoma Metastatic
Site of the node can help localize the primary Supraclavicular nodes can be non head & neck 10 Breast & Lung most common GI tract, Prostate, Testicular Eponym*

11 Lymph Node Levels Memorial Sloan- Kettering

12 Lymph Node Level Likely Primary Site

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15 Cases

16 7 Year Old Boy Small lump middle of neck Asymptomatic
Otherwise healthy Physical 1.5cm, firm lump middle neck Moves up with tongue protrusion What now? ? FNA ? Eponym

17 65 Year Old Man Asymptomatic 2 cm lump Right submandibular triangle
Chews tobacco, no EtOH Remainder history negative Physical 2 cm firm lump ? Submandibular gland on Bimanual Remainder negative FNA – Mucoepidermoid Ca What now?

18 38 year old Woman Asymptomatic Referred by GP for neck nodes
History entirely negative Physical Multiple nodes levels 3 & 4 Right side Small nodule Right Thyroid Likely Diagnosis? FNA – Papillary Ca What now?

19 56 Year Old Man Asymptomatic Lump Left Neck
Heavy Smoker, occasional EtOH No past history or family history Physical Exam Hard lump L neck anterior triangle Otherwise negative despite being thorough FNA – Squamous Cell Carcinoma What Now?

20 A 43-year old man notes shortness of breath. He is a non smoker
A 43-year old man notes shortness of breath. He is a non smoker. His wife points out that his face has become slightly swollen. On examination, his blood pressure is normal. His pupils are equal and respond to light. Dilated veins are noted around the shoulders, upper chest, and face. An x-ray of the chest reveals an opacity in the superior mediastinum. What is the most likely diagnosis? (A) Thymoma (B) Neurogenic tumor (C) Lymphoma (D) Teratodermoid tumor

21 This 19 year old girl had a two-week history of a painless swelling in the left jugulo digastric region. FNAC demonstrated benign squamous cells, cellular debris and cholesterol crystals. CT scan demonstrated a well circumscribed cystic mass, anterior to the sternomastoid muscle. This is a typical ?

22 This young woman had a one-week history of a rapidly enlarging mass in the upper right neck with localised tenderness. The CT scan again demonstrates a well circumscribed unilocular cyst, with a smooth wall

23 This young man has a prominent painless lymph node in the jugulodigastric region. Fine needle aspiration biopsy indicated a diagnosis of Hodgkin’s Disease. The 40 year old man (inset) has a lump in an identical position, also painless and present for months. Fine needle aspiration biopsy confirmed the diagnosis of metastatic squamous cell carcinoma from a tonsil cancer. He was a non smoker.

24 The man is 60, a heavy smoker and presents with a hoarse voice and large mass in the right upper neck. Fine needle aspiration biopsy showed necrotic debris and the CT scan demonstrates a unilocular cystic mass. The cyst wall is irregular and this is metastatic squamous carcinoma, which has undergone cystic degeneration. The primary cancer was in the hypopharynx

25 This man has nasopharyngeal carcinoma with multiple metastatic lymph nodes in the posterior triangle, bounded by the clavicle below, sternomastoid muscle anteriorly and the trapezius posteriorly..

26 The young man had a firm, but not hard submandibular swelling which had been present for 5 years. The CT scan on the right demonstrates a midline dermoid cyst. This is a well localised benign congenital lesion.

27 This young woman, aged 25, has a well localised swelling just below the hyoid bone, which elevates on protrusion of the tongue. The CT scan on the right is from another patient but demonstrates identical pathology of a well circumscribed cystic structure lying anterior to the thyroid cartilage - thyroglossal cyst.

28 This young woman has a prominent right thyroid nodule
This young woman has a prominent right thyroid nodule. The appropriate investigations are FNAB and serum TSH.

29 This boy, aged 14, presented with a cystic mass in the left submandibular region. Needle biopsy demonstrated the presence of mucoid material and the CT scan shows a cystic mass lying anterior to the left submandibular salivary gland. This is a typical plunging ranula and is due to extravasation of mucoid saliva from the sublingual gland

30 This elderly man has a large left submandibular mass
This elderly man has a large left submandibular mass. An SCC of the cheek was removed a year earlier. FNAB showed metastatic SCC and the CT scan demonstrates a large cystic mass with a septum, consistent with metastatic cancer.

31 This 45 year old Asian woman, recently migrated to Australia, presented with a supurating mass in the right submandibular region. A diagnosis of tuberculosis was made following culture of tissue from the mass

32 Questions/Comments