dr. farid al-zhrani 6 / 2 /1428 h approach of the neck mass presented by : dr. farid al-zhrani r1 (...

Dr. Farid Al-ZhraniDr. Farid Al-Zhrani6 / 2/ 1428 H

Approach of the neck massApproach of the neck mass

Approach of Approach of the neck massthe neck mass

Presented By :Presented By :

Dr. Farid Al-Zhrani Dr. Farid Al-Zhrani

R1 ( ENT )R1 ( ENT )



The general definition of a neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles .D

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Definition



The prominent landmarks of the neck are:

1. hyoid bone ,

2. Thyroid cartilage ,

3. Cricoid cartilage ,

4. Trachea,

5. Sternocleidomastoid muscles .



The anterior triangle is delineated by:

1. The anterior border of the SCM laterally ,

2. The midline medially ,3. The lower border of the

mandible superiorly.

The SCM divides each side of the neck into two major triangles, anterior and posterior.



The borders of the posterior triangles are:

1. The posterior border of the SCM anteriorly,

2. The clavicle inferiorly ,3. The anterior border of the

trapezius muscle posteriorly.



The thyroid gland : is usually palpable in the midline below the thyroid

cartilage .

The parotid glands : are located in the preauricular area on each side in the lateral neck. The tail of each parotid gland extends below the angle of the mandible,

inferior to the earlobe .



Submandibular glands : are located within a

triangle bounded by.… the sternocleidomastoid

muscle, the posterior belly of the digastric muscle, and the body of the mandible.

Lymph nodes :

are located throughout the head and neck

region.



FIGURE 2. Lymph node groups with the most likely sites of the primary lesion.



1. History.

2. Physical examination.

3. Investigation.

4. management.



The evaluation of any neck mass begins with a careful HISTORY . The history should be taken with the differential diagnosis in mind because directed questions can narrow down the diagnostic possibilities and focus subsequent investigations. For example, in younger patients, one would tend to look for congenital lesions, whereas in older adults, the first concern would always be neoplasia.



the differential diagnosis



*Personal data-:

1 .Age.

2 .Sex.

3 .Nationality.

*HPI-:

1 .Duration . 2. Location .

3 .Size . 4. How notice.

5 .Painfull / painless . 6. Other masse .

7 .Progression . 8. Trauma.



*Systemic Review-:

1 .Symptoms of hypo. OR hyper. THYRODISM.

2 .Symptoms which indicate malignancy.

3 .Respiratory Symptoms .

4 .GI Symptoms.

5 .Symptoms which indicate infectious / inflammatory process . ( fever , wt loss , night sweat

6 .Head & Neck Symptoms.

7 .Compression Symptoms.



*The completion of History:

1 .PMH,

2 .PSH.

3 .FH.

4 .Medication & radiation.

5 .Social History : smoking , alcohol , contact with T.B.

6 .Travel History.



Examination of the head and neck is challenging in that much of the area to be examined is not easily visualized. Patience and practice are necessary to master the special instruments and techniques of

examination .



*General Examinations-:

1 .Vital Signs.

2 .General appearance of the pateint.

*Local Examination-:

1 .Inspection:

a. site . b. shape.

c. color . d. relation to deglutition.

e. relation to tongue protrusion.



2 .Palpation:

a. temperature . b. tenderness.

c. size . d. surface.

e. edge . f. consistence .

g. fluctuation . h. pulsatility.

i. relation to skin . j. mobility.

k. relation to underlying structures.



3 .Percussion: on the sternum for retrosternal extension of

the thyroid.

4 .Auscultation: for bruits.



*Complete Head & Neck Examination:

1 .look to the head for any mass or ulcer.

2 .examine L.N.



3 .examine thyroid.

4 .ear , nose & throat examination.



6 .laryngoscope.

55 . .Mouth examinationMouth examination. .

7 .esophagi scope.



*Systemic Examination:

1 .Respiratory.

2 .GI.



# #SimpleSimple- : - :

# #DiagnosticDiagnostic- : - :

# #SimpleSimple- : - :

# #DiagnosticDiagnostic- : - :



11 . .CBC :-CBC :- ( ( infection , lymphoma ……..etc.infection , lymphoma ……..etc. ) ). .

22 . .U/E :-U/E :- ( ( Parathyroid Parathyroid ) ). .

33 . .TFT :-TFT :- ( ( ThyroidThyroid ) ). .

44 . .PTH :-PTH :- ( ( ParathyroidParathyroid ) ). .



55 . .Calcitonin . Thymoglobulin :- Calcitonin . Thymoglobulin :- ( ( ThyroidThyroid ) ). .

66 . .Tuberculine test :-Tuberculine test :- ( ( T.B.T.B. ) ). .

77 . .CXR :-CXR :- ( ( Lung lesionsLung lesions ) ). .



Fine Needle Aspiration Biopsy (FNAB) -

# Currently, FNAB is the STANDARD of diagnosis for neck masses.

#Indication:

Any neck mass that is not an obvious abscess and persists following prescribed antibiotic therapies .



2. Also may allay patient fears for malignant disease.

3. Helps the clinician differentiate carcinoma from lymphoma, which can prevent unnecessary panendoscopy.

#Contraindication:

There are NO contraindications to FNAB.

#Benefits:

1. FNAB separates inflammatory and reactive processes that usually do not require surgery from neoplastic lesions, either benign or malignant.



#Miscellaneous:

1. Pulsatile neck masses may represent a carotid body tumor, and although many clinicians prefer not to biopsy these lesions, the fine gauge of the needle reduces bleeding complications.

2. Needle-track seeding of tumor is not a concern with the fine needles used today .

3. FNAB can also be performed in children,



Ultrasonography -

With the current accuracy of FNAB, this study has become less important in the work-up of the neck mass. However, it is sometimes useful in differentiating solid from cystic masses and congenital cysts from solid lymph nodes

and glandular tumors.



Radionucleotide Scanning –

# Benefits: 1. This imaging technique can

differentiate a mass from within a gland from one outside a glandular structure.

2. Also indicate the functionality of the mass .

3. This is particularly important for salivary and suspected

thyroid gland masses .



Computed Tomography (CT) – # CT scanning of the neck has

become a very helpful tool in diagnostically difficult cases.

# Benefits: 1. It can distinguish cystic from

solid lesions.

2. Define the origin and full extent of deep, ill-defined masses.

3. When used with contrast can delineate vascularity or blood

flow .



4. In patients with metastatic SCCa to the neck from an unknown primary, CT should be obtained to detect an unknown primary lesion.

5. To help with staging purposes .

N.B. : Lucent changes within nodes, size larger than 1.5cm, and loss of sharpness of nodal borders are often signs of metastatic carcinoma.



Magnetic Resonance Imaging – # MRI provides much of the

same information as CT.

# It is currently better for upper neck and skull base masses due to

motion artifact on CT .

# With contrast it is good for vascular delineation and may even substitute for arteriography in the pulsatile mass or mass with a bruit or thrill.



FIGURE. Evaluation and management of a neck mass in the adult patient. (CT = computed tomographic; PPD = purified protein derivative)



SummarySummary# The differential diagnosis of neck masses is extensive.

#Age of the patient is important.

# A thorough work-up including an accurate history and

complete head and neck examination often-: narrows the diagnostic possibilities, thus obviating the

need for excessive testing and invasive procedures .



# The fine needle aspiration biopsy has become an invaluable tool to aid clinicians in the evaluation of the neck mass and is safe, accurate, and cost-effective

with minimal complications .

# The possibility of malignancy in any age group, especially in the late adult group.

# Close follow-up and aggressive approach is essential to a favorable outcome.

SummarySummary

dr. farid al-zhrani 6 / 2 /1428 h approach of the neck mass presented by : dr. farid al-zhrani r1 (...

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