Download Cervical Nodes: When to worry and what to do.

Cervical Nodes:
When to Worry and What to do.
Donna Sutherland
MD, FRCSC
CancerCare Manitoba, Head and Neck
Surgery
University of Manitoba, Department of
Otolaryngology
Objectives
Be familiar with various types of masses that
present in the neck
Give a differential diagnosis of a neck mass
Know the risk factors for Head and Neck cancer
Be aware of the historic and clinical features
concerning for malignancy
Describe the appropriate clinical work-up of a
neck mass
History
Location
Onset / Duration
Assoc. pain
Fluctuation in size
Single or multiple
Fever, chills, sweats
Weight loss
H & N cancer risk factors
- smoking, alcohol use
H & N Symptoms
- hoarseness
- dysphagia, odynophagia
- throat pain
- cough
- FB sensation
- bleeding
- otalgia
Physical Exam
Location
Size
Consistency
Mobility – fixed?
- moves w/swallowing?
- moves w/tongue
protrusion?
Full Head and Neck
Exam
- scalp, skin
- ears, nose
- nasopharynx
- oral cavity
- oropharynx
- larynx
- cranial nerves
- neck exam
Physical Exam
Have a system for your examination
The neck can be broken down into regions
– Anatomical triangles
– Named lymph node groups
– Numbered lymph node regions
Neck Masses
I. Neoplasms
II. Infections
A. Benign
III. Congenital
B. Malignant
IV. Miscellaneous
II. Infections
A. Abscess
B. Cervical
lymphadenitis
1. Suppurative lymph
node
2. Deep neck space
abscess
1.
2.
3.
Bacterial
Granulomatous
Viral
Treat cervical adenitis with
Antibiotics only if evidence of a
bacterial infection is found on
clinical exam.
III. Congenital Masses
A.
B.
C.
Thyroglossal Duct Cyst - midline
Branchial Cleft Cyst - lateral
Dermoid - midline
Treatment – Surgical excision
I. Neoplasms
A. Benign
- benign thyroid gland tumors
- benign salivary gland tumors
- lipomas
- schwannomas (nerve sheath)
- vascular tumors
Salivary Gland Disease
Inflammatory - sialadenitis
- sialolithiasis (calculi /stone)
Neoplastic
- benign
- malignant
Vascular Tumors
Paragangliomas (Glomus tumors)
z
z
z
Hemangioma
Lymphangioma
Arteriovenous malformations
I. Neoplasms
B. Malignant
1. Primary
- Lymphoma
- Thyroid carcinoma
- Salivary gland carcinoma
- Sarcoma
2. Metastatic - Head & Neck primary
- Infraclavicular primary
Head and Neck Cancer
Most common
histology –
Squamous cell
carcinoma
Most common sites Oral cavity
Larynx
Head & Neck Cancer
Etiology: Smoking and alcohol
Head & Neck Cancer
Epidemiology: Risk increases with age,
males > females
Head & Neck Cancer
Common Presenting Symptoms
– Larynx – Hoarseness, throat pain, ear pain,
dysphagia, odynophagia
– Oral cavity – Growth with ulceration
- pain & tenderness
– Neck mass - Spread to lymph nodes
(WORRY)
** Investigate oral lesion, throat
symptom, or neck mass
present > 4 weeks
Oral Cancer (Squamous cell carcinoma)
Benign oral growths
Fibroma
Papilloma
Mucocele
Leukoplakia
Benign oral ulcers
Traumatic
Aphthous ulcer
(Canker sore)
Relationship Between Age and
Neck Mass Etiology
Pediatric (0-15yrs)
Congenital>Inflammatory>>Neoplastic
Young Adult (15-50)
Inflammatory>Congenital>>Neoplastic
Older Adult (50+ yrs)
Neoplastic(malignant)>Inflammatory>>
Congenital
When to (Worry About)
Investigate a Neck Node
- Neck Node >1.5-2 cm
- persistent adenopathy > 4
weeks
- neck node in patient with no
preceding history of URTI or H&N
infection
- neck node or upper AD
complaint not explained by clinical
exam (older, smoker, EtOH)
Fine Needle Aspiration
Biopsy
** The single most useful
diagnostic test for a neck mass**
Evaluation of a Neck Mass
Warning:
**
DO NOT PERFORM AN
INCISIONAL BIOPSY OF A
NECK MASS **
Imaging for a Neck Mass
CT scan
MRI scan
Ultrasound
Plain x-rays
Sialogram
Thyroid nuclear scan
Angiography
Take Home Points
Use a headlight and free up both hands to
perform a head and neck exam
The most useful investigation for a neck mass
after your history and physical is a FINE
NEEDLE ASPIRATION BIOPSY
Do not perform an incisional biopsy on a neck
mass prior to a FNA biopsy
Do not treat an unexplained H&N symptom or
neck mass with repeated courses of antibiotics
Head and Neck Cancer - Key Points
Histology - Squamous Cell Carcinoma
Etiology - Smoking / Alcohol
Common sites - Oral cavity & larynx
Common presenting symptoms
Oral growth / ulcer
Hoarseness, throat pain, ear pain, odynophagia
Neck mass
Consider the diagnosis
Biopsy
– Biopsy oral / pharyngeal lesions
– Fine Needle Biopsy of Neck Masses
So, When to Worry?
Cervical node >1.5 – 2 cm, present for >4
weeks
Cervical node with no preceding history of
URTI or H&N infection
Persistent voice, throat or swallowing
complaint not explained by physical exam