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)
2)
3)
4)
Physical exam and history
Fine Needle Aspiration
Imaging if FNA positive
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)
2)
3)
4)
Progressively enlarging
nodes
A single asymmetric
node
A persistent nodal mass
without antecedent
active signs of infection
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
- Thyroid
Melanoma
Neuroepithelial tumors
Connective Tissue tumors
- lymphoma
- sarcoma
Squamous cell carcinoma
T1 > 2 cm,
T3 > 4 cm
antrum
T2 2 – 4 cm
T4 invasion of
N0 – no positive nodes
N1 – single node < 3 cm
N2a – single node 3 – 6 cm
N2b – multiple homolateral nodes
< 6 cm
N2c – multiple bilateral nodes < 6
cm
N3 -- 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 SCC
Chemotherapy – cisplatin and 5-FU
Stage I – II -> radiotherapy or surgery
Stage III – IV -> combined radiotherapy and
surgery
Unknown 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