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 its lateral, assume its malignant until otherwise diagnosed 3. Dont 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, its probably thyroidal 7. If it moves with tongue protrusion, its probably a Thyroglossal cyst 8. If its near the ear, beware - its also near the facial nerve 9. If its 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 (Zenkers diverticulum) is not palpable

 Patients age

History

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 Transillumination
Carotid body tumour Glomus carotidum Paraganglioma Chemodectoma Non-chromaffin argentaffinoma

Clinical examination
Lumps in General Site Size Shape Consistency Deep & Superficial attachments Nature of surface and edge Fluctuance Pulsation, bruit Transillumination

useful for clues

Clinical examination
BUT, even with experience, its difficult to actually diagnose the pathology Some signs are confusing, dont 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 couldnt 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 we need to see the scans

Need good quality imaging (and reporting) 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 (Adams 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
do a Neck ultrasound or CT scan excise cyst, and the body of the Hyoid bone
Stephen Kleid ENT/HN surgeon

Might be the only thyroid tissue Sistrunks operation

Neck Lumps for Medical Students 2008

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 dont bother with

Technetium Unclear Nuclear scan

Not accurate enough to help

Look for other clues

Stridor Hoarseness, dysphagia, odynophagia (pain on swallowing) Other lumps Horners syndrome

Lateral Neck Lumps

Assume its malignant , until proven otherwise Even with CT & MRI I cant 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 Zenkers 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 FNAs, 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 its lateral, assume its malignant until otherwise diagnosed 2. Dont 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
Its 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 Warthins 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