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Neck lumps

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					Stephen Kleid - ENT/Head & Neck Surgeon
       Western Hospital
       Peter MacCallum Cancer Centre

NECK LUMPS
           Neck lumps – 11 Golden Rules
1. There are very few neck lumps diagnosable clinically

2. If it’s lateral, assume it’s malignant until otherwise diagnosed

3. Don’t try to excise or biopsy a neck lump, until you know what it is

4. Fine Needle Aspiration for Cytology is safe & reliable (with limitations)

5. Metastatic neck nodes usually arise from the Head & Neck region

6. If it moves with swallowing, it’s probably thyroidal

7. If it moves with tongue protrusion, it’s probably a Thyroglossal cyst

8. If it’s near the ear, beware - it’s also near the facial nerve

9. If it’s lateral, check for pulsation - it could be the Carotid bulb

10. Beware Accessory nerve (XI)when operating on the neck (also X, XII)

11. A Pharyngeal pouch (Zenker’s diverticulum) is not palpable
                                           History
• Patient’s age
  • Children - more likely to have benign lumps
  • Adolescents – similarly benign, but also lymphomas
  • Adults – assume malignant until proven otherwise

• Duration of lump – uncertain relevance
  • Recent onset, tender – inflammatory
  • Years – benign
  • 1-2 months – ??

• Tenderness
• Growth
• Other throat symptoms
  • pain, dysphagia, hoarseness
                        Clinical examination
Lumps in General
• Site
• Size
• Shape
• Consistency
• Deep & Superficial attachments
• Nature of surface and edge
• Fluctuance
• Pulsation, bruit
• Transillumination


Examine lymphatic regions   ( Palpate from behind the patient )
                                              Clinical examination

Lumps in General
• Site - midline, lateral upper, lower, anterior, posterior
• Size
• Shape
• Consistency
• Deep & Superficial attachments
• Nature of surface and edge
• Fluctuance
• Pulsation, bruit
• Transillumination

   Neck Lumps for Medical Students – 2008 –    Stephen Kleid – ENT/HN surgeon
                             Clinical examination
Lateral
 •   More likely to be a lymph node - ?metastatic
 • ?High, mid, low - in neck, suggests site of origin
 • Posterior triangle – suggests site of origin


 •             Examine lymphatic regions


Midline
 • Probably Thyroid origin
 • Low/mid neck - Does it move with swallowing?
          = attached to larynx – probably Thyroidal
 • Mid/High - Does it move with tongue protrusion?
                       (keep mouth open, and the jaw still)
          = attached to Hyoid - Thyro-glossal cyst
                      Clinical examination

Lumps in General
• Site
• Size
• Shape
• Consistency
• Attachments
• Surface, edge
• Fluctuance
• Pulsation, bruit        • Carotid body tumour
• Transillumination         Glomus carotidum
                            Paraganglioma
                            Chemodectoma
                            Non-chromaffin argentaffinoma
                        Clinical examination
Lumps in General
• Site
• Size
• Shape
• Consistency
• Deep & Superficial attachments   useful for clues
• Nature of surface and edge
• Fluctuance
• Pulsation, bruit
• Transillumination
                         Clinical examination
BUT, even with experience,
  it’s difficult to actually diagnose the pathology
Some signs are confusing, don’t match with the others
Some signs are difficult to elicit

As diagnosticians, we have to look a bit beyond the
  obvious lump, the images, and search for clues
More mistakes are made in Medicine from not looking,
  than not knowing
   Fine Needle Aspiration – for Cytology
The single most useful test for
  diagnosing Neck lumps

• Freehand
    or
• Ultrasound-guided

• Need experienced cyto-pathologist

• If uncertain or confusing result
    Repeat the FNA

• For Thyroid lumps, “Follicular tumour”
  on FNA cannot differentiate benign
  from malignant (20% are malig.)
    Requires hemithyroidectomy
                                               An interesting case
• Before I had seen her, based on a CT done in Mt. Gambier,
  which diagnosed a very rare condition, it was her 6th trip to
  Melbourne, for Clinic visits and various scans, with no
  diagnosis.
• Each scan report proffered a new diagnosis, and
  recommended the next test - and all of them were uncertain
• When I saw her, she had left her films at home !
       – I had only the reports
• After thorough examination, I still couldn’t confirm a
  diagnosis for her lump.

• I performed an FNA in the Clinic – awaiting special stains
        - Metastatic Papillary carcinoma of the thyroid
    Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
    An interesting recent case – Lessons
• Common things occur commonly
   •     Rare variations of common conditions are more common
       than rare conditions
• Need good quality imaging (and reporting)
       – we need to see the scans
• X-rays are only shadows of the truth
• Get a Fine Needle Aspiration, for a tissue diagnosis
• ALL tests have an error rate – specificity, selectivity
     – you need to know it for any test you order
   • FNA cytology is not always correct
      - sometimes you need to repeat it
      - Ultrasound-guidance helps
      - Cytologist in attendance helps
                                           “Normal” neck lumps
Lateral

• Lymph node
• Mastoid tip
• Parotid tail
• Transverse process of Atlas
• Submandibular gland
• Carotid - bulb, bifurcation
• Greater cornu of hyoid bone
• Thyroid lamina
• Cervical rib

    Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
                                         “Normal” neck lumps
Midline/paramedian

• Lymph nodes – submental
• Hyoid bone
• Thyroid lamina (Adam’s apple)
• Cricoid cartilage
• Thyroid gland




  Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
                                         “Midline” neck lumps
Thyroglossal Cyst
• Congenital remnant of the thyroid tract
   •       from tongue base to lower neck
• So is the Pyramidal lobe
• Moves up with tongue protrusion
   •       (keep jaw still, mouth slightly open)
• Can be malignant (rarely)
   •       do a FNA
• Might be the only thyroid tissue
   •      do a Neck ultrasound or CT scan
• Sistrunk’s operation
   •       excise cyst, and the body of the Hyoid bone

  Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
                                           “Midline” neck lumps
Thyroid lumps
• Solitary lump
• Dominant lump in a Multi-Nodular goitre
• Multi-nodular goitre

• Guess what test you do first?
  • Get a FNA
• Beware previous Radiation exposure
  • especially Pre-pubertal
  •  Acne RT stopped in Melbourne ~1972, none for Tonsils
  •  Ukrainians (Chernobyl 1986)
  •  PH - Childhood ca - 30% of glands with lump(s) - malignant
    Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
                                   Thyroid Lumps
• >90% of solitary thyroid lumps are benign

• FNA/cytology results
   • Benign - Observe, repeat FNA in 3 months
   • Malignant
   • Uncertain (eg – Follicular tumour)
   • Non-diagnostic




• I don’t bother with
  Technetium Unclear Nuclear scan
   • Not accurate enough to help
                          Look for other clues
• Stridor
• Hoarseness, dysphagia, odynophagia (pain on swallowing)
• Other lumps
• Horner’s syndrome
                                             Lateral Neck Lumps
Assume it’s malignant , until proven otherwise
Even with CT & MRI – I can’t tell
• Metastatic Ca in a Lymph node
• Metastatic Melanoma
• Lymphoma

Benign
• Reactive Lymph node
• Branchial cyst
• Miscellaneous cyst, Lipoma etc
• Carotid body tumour (very rare) - paraganglioma
• NB – Zenker’s diverticulum (Pharyngeal pouch) is not palpable


  Neck Lumps for Medical Students – 2008 –    Stephen Kleid – ENT/HN surgeon
                                                            Branchial cyst
• ? Pathogenesis
   • Remnant of 2nd Pharyngeal cleft, trapped under Platysma (2nd arch)
     as it moves down to cloak the neck and obliterated the clefts
   • Metaplastic Lymph node
• Children, or young adults – occasionally older
• Can “appear” suddenly – presumably due to infection
   • can be occult infection
   • or can be overtly infected – abscess
• Diagnose with FNA/cytology
   • Usually recur after aspiration/drainage
• If two –ve FNA’s, and H&N exam clear , then can safely excise it

• Almost every metastatic node excised, then sent to Peter Mac, has a
  note from surgeon – “I though it was a Branchial cyst”
• The others “thought it was Lymphoma”
    Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
Golden rules         Metastatic Cervical Node
1. If it’s lateral, assume it’s malignant until otherwise diagnosed

2. Don’t try to excise or biopsy a neck lump, until you know what it is

3. Fine Needle Aspiration for Cytology is safe & reliable

4. Metastatic neck nodes usually arise from the Head & Neck region
                                  Metastatic Cervical Node

 “Unknown primary”
• It’s not an “unknown primary” until you look properly for the primary
• Clinical examination with Head light, Palpate tonsils and Base of
  Tongue, Flexible nasendoscopy
• CT Neck – from skull base to clavicles, (and CT Chest)


• The site and type of node gives us some clues


• Nasopharynx – esp. in Asians (100X), also Mediterranean's(10X)
   •     Check ear for effusion (glue ear)
• Tonsillar fossa
• Base of Tongue
• Skin
       Neck Lumps for Medical Students – 2008 –   Stephen Kleid – ENT/HN surgeon
                      Metastatic Cervical Node




• This man had an Open Biopsy, then Radiotherapy
• When it recurred, it fungated out through the scar
• It progressed (untreatable)      a miserable way to die
 Accessory Nerve
      Palsy

This is not a web-site you would
want to feature on




    Golden rule # 10
 Beware Accessory nerve
when operating on the neck

Also Vagus and Hypoglossal
                                    Parotid lumps
• Parotid = “para otic” = near the ear
• Most parotid lumps are beneath the ear lobe, not pre-
  auricular
• Because there is more volume of parotid gland there


• Most parotid lumps are beneath the ear lobe
     - not pre-auricular


        Golden rule # 8
   Beware lumps near the ear
  They are also near the facial
             nerve
                                      Parotid lumps
• 2/3 are Benign
• Pleomorphic adenoma – benign mixed salivary tumour
• Warthin’s tumour – Papillary lymphoid cystadenoma
• 1st Branchial arch cyst


• 1/3 are Malignant
• Metastatic skin cancer (in Australia) – SCC, melanoma
• Actinic cell cancer
• Muco-epidermoid ca
• Lymphoma


• How do you tell? Guess
• Do a Fine Needle Aspiration for Cytology
      A tragic case of Parotid misadventure
• 1984 – referred because of multinodular recurrent Pleomorphic
    adenoma (after incisional biopsy, followed by parotidectomy)


• ? Surgery – risk of facial nerve damage – further recurrence
• ? Radiotherapy – risk of malignancy, further recurrence


• 1984 - referred because of multinodular recurrent Pleomorphic
    adenoma (after incisional biopsy, followed by parotidectomy)
• 1986 - revision surgery – facial nerve had to be taken, graft failed
•        - post-op Radiotherapy
• 1996 - SCC in temple skin (radiation-induced)


• 2000 - Recurrent Pleomorphic Adenoma
          - Facial palsy, Deformity, a virtual “hermit”

				
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