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Neck Lumps Dr Deborah Amott ENT Surgeon [email protected] Core Presentations By the end of this year, you should be able to perform a competent medical interview, physical examination and suggest a basic investigational plan for a patient presenting with this symptom. An accurate diagnosis is: 90% History 9% Examination 1% Investigations Getting the Words Right Clinical Assessment = History + Examination Diagnosis = Clinical Assessment + Investigation/s Management = Diagnosis + Treatment Lumps and Bumps: The Mnemonic She Cuts The Fish PERfectly Three Ss Site - describe location briefly Size - use your hand and fingers to estimate if you do not have a ruler with you Surface/overlying skin Three Fs Fluctuance - ?fluid-filled cyst Fixation - ?is it fixed to the underlying tissue or to the overlying skin Fields - draining lymph glands in the area Three Cs Colour Contour - is the lump well-defined or irregular Consistency - ?soft/firm/hard Finally, remember to check for whether the lump is: Pulsatile (Is it an aneurysm?) Expansile (Is it an aneurysm?) Reducible (Is it a hernia?) Three Ts Tenderness Temperature - Is it hot/inflamed? Transilluminable Age of Patient + Location of Lump + Acuity of Symptoms = Likely Diagnosis Neck: Triangles Normal Structures Present? Neck Mass: DDx Inflammatory/Infectious: Acute: bacterial lymphadenitis, glandular fever, reactive lymphadenopathy due to URTI. Subacute/chronic lymphadenitis: TB/atypical mycobacterium, cat scratch disease Neck abscesses: traumatic, foreign body, dental abscesses Salivary: sialodenosis/itis/lithiasis, Sjogren’s syndrome Granulomatous disease: Sarcoidosis, Kimura’s Disease etc Neoplasms Lymph nodes: primary (lymphoma/leukaemia) vs. metastatic (SCC, melanoma, Merkel Cell carcinoma, salivary gland, thyroid, intra-abdominal or thoracic malignancy) Salivary Gland Sarcoma Thyroid: adenoma vs. carcinoma Nerve derived: neuroma, neurofibroma, schwannoma, sarcomas Paraglanglioma (benign vs. malignant) Neck Mass: DDx Lymphovascular malformations Haemangioma Lymphagioma Cystic hygroma AVMs Congenital abnormalities Ectopic thyroid gland Branchial cleft cyst Dermoid Thyroglossal duct cyst Thyroid • Multinodular or diffuse enlargement Other: • Mediastinal masses with neck extension Histiocytosis Castleman’s disease Gout/psuedogout ad infinitum…. Ask 4 Questions… What is the most likely diagnosis? What is the most IMPORTANT diagnosis? Could this be life-threatening? What information do I need to confirm my diagnosis? What’s my time frame? Context of this Symptom Symptom itself: Acuity Duration Severity Fixed/Variability Progression Triggers/Relievers Associated features: what else is changing? Local, adjacent structures Regional Distant organ dysfunction Systemic symptoms Patient: Demographics: age, sex, race, ethnicity Lifestyle: profession, hobbies, smoking, alcohol, other drugs, other carcinogens, diet. Immune status: Immunosuppressed/Atopic/A utoimmune disease Comorbidities, previous medical conditions or treatment. Environment: season, latitude, humidity/temperature, recent events. General Pathological Processes VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs I-idiopathic C-congenital A-anoxia/acid-base imbalance/auto-immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic: too much vs. too little of an otherwise good thing Neck Lumps: Examination Examine the lump Examine the rest of the neck Lymph nodes, Parotid, Thyroid, Vessels Full ENT examination (including flexible nasendoscopy) Skin Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic Top 3 Infection Infection Infection Infection Congenital: lymphovascular malformation, ectopic thyroid, thyroglossal duct cyst, branchial cleft cyst Neoplasm: leukaemia/lymphoma Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic Top 3 Infectious/Inflammatory Neoplasia Congenital Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic Top 3 Infectious Neoplasia Aerodigestive tract, skin, salivary, thyroid Other Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic Top 3 Neoplasia Vascular Infectious/Inflammatory Investigation Know the question you want to answer. Only order an investigation if the result will affect your management A proper initial clinical assessment and then repeated thorough clinical assessment is always better than multiple non-targeted tests. Recruit help Investigations Repeated clinical assessment is often the most appropriate ‘investigation’. Blood tests Microbiology: bacteria, fungal, viral Biopsies: FNA, incisional, excisional Imaging: plain XRs, US, CTs, MRI, PET, other (SPECT, nuclear medicine etc). Other: resp function tests, endoscopy, oximetry, ABGS etc. Operations: diagnostic endoscopy, open operations Imaging Plain XRs Ultrasound Computed Tomography Magnetic Resonance Imaging Positron Emission Tomography Nuclear Medicine Scans The weird and wonderful Biopsy Options Fine needle aspiration Incisional: ‘wide needle/core’, punch, shave, scalpel Excisional biopsy Wide local excision (“Halsteadian”, “en bloc”, “R0 resection”) Treatment Behavioural: avoid triggers, diet, exercise, sleep, environmental modification, mood management Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements etc Pharmacologic: topical, enteral, transcutaneous, injections Interventional Minimal: endoscopic, angiography, etc Maximal: open surgery, radiation etc What’s the Cost-Benefit ratio? ENT Handbook References