Wilhema M.

Villan, MD
 General Considerations
• Patient age
– Pediatric (0 – 15 years): 90% benign
– Young adult (16 – 40 years): similar to
pediatric
– Late adult (>40 years): “rule of 80s”
• Location
– Congenital masses: consistent in location
– Metastatic masses: key to primary lesion
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 General Considerations

• Location of mass
–Congenital and
developmental consistent
–Metastatic masses - help
identify possible primary
• Treat each case individually *
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General Considerations
 Diagnostic Steps
• History
–Careful and complete
–Developmental time course (acute,
chronic)
–Associated symptoms (dysphagia,
otalgia, hoarseness)
–Personal habits (smoking, alcohol)
–Prior trauma, irradiation or surgery
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 Diagnostic Steps
• Physical Examination
– Complete head and neck exam
– Inspect / Visualize all mucosal surfaces
(direct, indirect)
– Palpate oral and pharyngeal surfaces
– Emphasize location, mobility and
consistency of neck mass (vascular, salivary,
nodal, inflammatory, congenital, neoplastic)
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 Empirical Antibiotics
• Inflammatory mass suspected
• Two week trial of antibiotics
• Follow-up for further investigation

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 Diagnostic Tests
• Fine needle aspiration biopsy (FNAB)
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Ultrasonography
• Radionucleotide scanning
• PET scan

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 Diagnostic Studies
• Fine needle aspiration biopsy (FNAB)
–Standard of care
–Indications
• Not obvious abscess
• Persists following antibiotics
–No contraindications (vascular?)
–Fine gauge needle (23 - 27)
–Skilled pathologist critical 9
 Diagnostic Studies
• FNAB continued
– Needle track seeding not a concern
– Bleeding complications reduced
– Can be performed in children
– Separates neoplasm from inflammatory &
carcinoma from lymphoma
– Minimum of four separate needle passes

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 Diagnostic Studies
• Computed Tomography (CT)
– Very helpful tool
– Solid versus cystic
– With contrast delineates
vascularity
– Metastatic masses
• Unknown primary and staging
purposes
• Lucent changes, >1.5 cm, loss of
sharpness
– Avoid contrast in thyroid masses
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 Diagnostic Studies
• Magnetic Resonance
Imaging (MRI)
–Similar information as
CT
–Better for upper neck
and skull base
–Infusion may
substitute for
arteriography 12
 Diagnostic Studies

• Ultrasonography
–Less important with advent of
FNAB
–Useful for solid versus cystic
(congenital cyst vs. lymph
node/glandular tumor)
–Noninvasive (pediatric)
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 Diagnostic Studies
• Radionucleotide Scanning
– Intra-glandular versus extra-glandular
– Functionality
– Salivary and thyroid masses
– FNAB preferred for thyroid nodules
• Solitary thyroid nodule
• Multinodular goiter with new increasing nodule
• Hashimoto’s with new nodule
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 PET scan

• PET-scan
–Pet scan indicates the functional
activity of a mass
–A more radio-intense mass has
greater metabolic activity and is
usually neoplastic
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 Nodal Mass Workup in the Adult
• Any solid asymmetric mass must be
considered metastatic until proven
otherwise
– Presenting symptom in 12% of cancers
– 80% are SCCa
– History of smoking and alcohol worrisome
– Suspicious symptoms and signs
• Ipsilateral otalgia with normal otoscopy
• Unilateral serous otitis media (nasopharynx)
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 Nodal Mass Workup in the Adult
• Indications for panendoscopy
– Positive FNAB (staging, search for primary,
synchronous primaries - 10 to 20%)
– Equivocal or negative FNAB in high risk
• Unknown primary
– Biopsy suspicious observed areas or suspicious
abnormalities on CT/MRI
– None - biopsy nasopharynx, tonsil (ipsilateral
tonsillectomy for jugulodigastric nodes), base of
tongue, and pyriform sinuses
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 Nodal Mass & Unknown Primary
• Open excisional biopsy
– Repeated exam and workup fail to reveal 10 with
an equivocal or negative FNAB
– 5% of the time
– Prepare for complete neck dissection
– Frozen section results
• Inflammatory or granulomatous: culture tissue
• Adenocarcinoma or lymphoma: close wound

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 Common Primary Tumors

• Thyroid Masses • Carotid Body and

Glomus Tumors
• Lymphoma
• Neurogenic Tumors
• Salivary Tumors
• Lipoma

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 Thyroid Masses

• A leading cause of anterior neck masses

• Children
– Most common neoplastic condition
– Male predominance
– Greater chance of malignancy
• Adults
– Mostly benign
– Female predominance
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 Thyroid Masses
• Lymph node metastatic
– 15% of papillary carcinomas
– 40% with malignant nodules
– Histologically in >90% (microscopic)
• FNAB is standard of care
– Decreases # of patients with surgery
– Increases # of malignant tumors found at surgery
– Doubles # of cases followed up
– Repeat negative aspiration in 1 month
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 Lymphoma
• More common in pediatric & young adults
• 80% of children with Hodgkin’s have neck mass
• Signs and symptoms
– Mass only, fever, hepatosplenomegaly, diffuse
adenopathy
• FNAB - 1st line; open biopsy if suggestive
• CT scans (H&N, chest, abdomen) & bone marrow biopsy

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 Salivary Tumors
• Any preauricular enlarging mass or at the
angle of the mandible is suspicious
• Benign - asymptomatic
• Metastatic - rapid growth, skin fixation or
cranial nerve palsies
• Open excisional biopsy preferred

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 Salivary Tumors
• FNAB
– Reduces # of patients with surgery by 1/3
– Distinguishes intra-glandular lymph nodes,
localized sialadenitis, benign cysts
– Accuracy >90% (better for benign)
– Sensitivity - 90%; Specificity - 80%
– May facilitate surgical planning or patient
counseling
• Prepare for total parotidectomy & nerve
sacrifice in unknown primaries
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 Carotid Body and Glomus Tumor
• Rare in the pediatric population
• Classical presentation
– Adult
– Pulsatile, compressible mass at carotid
bifurcation
– Mobile side to side
• Diagnosis confirmed by angiography or
CT
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 Carotid Body and Glomus Tumor
• Treatment
– Elderly adult
• Observation
• Irradiation to arrest growth
– Young adult
• Resection of small tumors
• Hypotensive anesthesia
• Preoperative embolization and
measurement of catecholamines release
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 Lipoma
• Over age 35 usually
• Ill-defined, soft masses
• Diagnosis confirmed by excisional biopsy

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 Neurogenic Tumors
• Peripheral nervous system tumors
• Arise from neural crest derivatives
• Include schwannomas, neurofibromas and
malignant peripheral nerve sheath tumors
• Increased incidence in NF syndromes
• Schwannomas occur most commonly
• MPNST uncommon in head and neck

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 Neurogenic Tumors
• Schwannoma
– Benign
– Any age, but most common 20 to 50 years
– Solitary, slowly enlarging, painless mass
– Medial tonsillar displacement
– Hoarseness (vagus nerve)
– Horner’s (sympathetic chain)
– Surgical excision is treatment of choice

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 Congenital and Developmental Masses

• Epidermal and Sebaceous cysts

• Branchial Cleft Cysts
• Thyroglossal Duct Cysts
• Vascular Tumors

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 Epidermal and Sebaceous Cysts
• Most common congenital mass
• Older age group most often
• Clinical diagnosis - movement and
elevation of overlying skin
• Excisional biopsy confirms

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 Branchial Cleft Cysts
• Late childhood or early adulthood
• Often appears rapidly after URI
• Skin erythema and tenderness after recent infection
• May express purulent material if sinus tract is
present
• Treatment is initial control of infection, followed by
surgical excision

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 Branchial Cleft Cysts
• 1st branchial cleft cyst
– 2nd most common
– Inferior or angle of the mandible or below the ear
lobe
– Close association with facial nerve possible
– Excision may require total parotidectomy and
facial nerve dissection

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 Branchial Cleft Cysts
• 2nd branchial cleft cyst
– Most common
– Underlying SCM
– Tract courses medial over 12th nerve and between
internal and external carotids
• 3rd and 4th branchial cleft cysts
– Rarely reported

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 Thyroglossal Duct Cysts
• Most common congenital neck mass
• Midline or near-midline mass
• Elevates on swallowing or protrusion of the tongue
• Differential: lymph nodes, dermoids, ectopic
thyroid tissue
• Surgical removal (Sistrunk) after resolution of
infection

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 Vascular Tumors
• Almost always present within 1st year
• CT/MRI help in diagnosis and defining extent of
lesion
• Lymphangioma
– Remain unchanged into adulthood
– Soft, doughy, ill-defined
– Treatment: excision for easily accessible or vital
function compromise

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 Vascular Tumors
• Hemangiomas
– Most often resolve spontaneously
– Bluish, compressible
– Surgical treatment
• Rapid growth
• Associated thrombocytopenia
• Involvement of vital structures
• After failure of medical therapy
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 Inflammatory Disorders
• Lymphadenitis
• Granulomatous lymphadenitis

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 Lymphadenitis
• Very common, especially during 1st decade
• Marked tenderness, torticollis, trismus, and
dysphagia
• Systemic signs of infection
• Initial treatment - directed antibiotics
• Close follow up

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 Lymphadenopathy
• Failure of antibiotics necessitates biopsy after
complete head and neck work-up
• FNAB indications
– Progressively enlarging nodes
– Solitary, asymmetric nodal mass
– Supraclavicular mass
– Persistent nodes without infectious signs

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 Lymphadenopathy
• Equivocal or suspicious FNAB in the
pediatric nodal mass requires open
excisional biopsy to rule out lymphoma
or granulomatous disease

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 Granulomatous Lymphadenitis
• Develop over weeks and months
• Minimal systemic complaints or findings
• Firm glands, fixation and injection of skin
• Common etiologies
– Typical Mycobacterium tuberculosis (adults)
– Atypical Mycobacterium tuberculosis (children)
– Cat-scratch fever (Bartonella henselae) (children)
– Actinomycosis, Sarcoidosis

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 Granulomatous Lymphadenitis
• Atypical TB
– Anterior triangle lymph nodes
– Brawny skin, induration and pain
– Usually responds to complete surgical excision
• Cat-scratch fever
– Preauricular or submandibular lymph nodes
– Spontaneous resolution 1-2 months
• Typical TB (rarely seen, posterior nodes)

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 Summary
• Extensive differential diagnosis
• Thorough work-up needed
• FNAB invaluable
• Malignancy should never be overlooked
• Close follow-up and aggressive pursuit of a
diagnosis essential

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