DIFFERENTIAL DIAGNOSIS & MANAGEMENT OF SOLID SWELLINGS OF DEEPTHI.B 2002 MBBS NECK
Metastases in cervical lymph nodes are common in head and neck cancers. • common sites of involvement in lymphoma. • Tuberculous lymphadenitis is common in South East Asia.
Cervical lymph nodes are composed of lymphoid tissue and are located along the lymphatic vessels in the neck. • about 300 lymph nodes in the neck • the lymph nodes are embedded in the soft tissues of the neck and are either partly or completely surrounded by fat
Classification • Level 1: Submandibular, submental. • Level 2: Internal jugular from skull base to carotid bifurcation. • Level 3: Internal jugular below carotid bifurcation to omohyoid. • Level 4: Internal jugular below omohyoid. • Level 5: Posterior triangle. (also known as accessory chain) • Level 6: Adjacent to thyroid. • Level 7: Tracheal esophageal groove and superior mediastinum.
NODAL PATHOLOGY • Malignant AdenopathyIs associated with a 50% reduction in long term survival.Abnormal (malignant) Nodes • Size:Greater than 1 centimeters • Hard, irregular, fixed nodes • Necrosis: Regardless of size. • Extracapsular spread: Regardless of size.
Staging information is necessary for selection for most appropriate treatment option. • 30% of malignant nodes are clinically undetected on physical examination due to deep location especially in retropharyngeal and high internal jugular chains. • Accuracy of nodal staging CT: 90-95% Physical exam- 75%
Clinical Nodal Staging • NX: Not assessable. • N0: No clinically positive nodes. • N1: Single clinically positive ipsilateral node less than or equal to 3 cm • N2: Greater than 3 cm, less than 6 cm • N2A: Single, ipsilateral. • N2B: Multiple ipsilateral. • N3: Greater than 6 cm • N3A: Ipsilateral. • N3B: Bilateral. • N3C: Contralateral
Extracapsular spread carries a grave prognosis and may be the best indicator of treatment failure. Signs of Extracapsular Spread • Spiculated margins. • Fatty invasion. • Encasement of vessels.
FNAC under local anesthesia in op or cytology clinic. Useful if malignancy is suspected. Advantage • Accurate histological diagnosis • No spread of tumor • If not palpable image guided aspiration under USG or CT
Accuracy Comparison CT versus MRI • CT = MR for detecting and sizing nodes. • CT better than MR for demonstrating necrosis. • CT better than MR for detecting extracapsular spread.
Nodes from Unknown Primary • Approximately 10% of patients with abnormal cervical nodes present without obvious primary. Most common sites for unknown primary: • Nasal Pharynx. • Pyriform Sinus. • Tongue Base. • Tonsillar Crypts. • Thyroid. • Lung. Knowledge of drainage patterns may help in search for primary.
Probable Source of Nodal Metastasis • Level 1: Oral cavity, submandibular gland. • Level 2: Nasal pharynx, oral pharynx, parotid, superglottic larynx. • Level 3: Oral pharynx, hypopharynx, superglottic larynx. • Level 4: Subglottic larynx, hypopharynx, esophagus, thyroid. • Level 5: Nasal pharynx, oral pharynx. • Level 6 & 7: Thyroid, larynx, lung. • Note: Bilateral nodes are common with cancers of soft pallet, tongue, epiglottis, and nasal pharynx.
Lymphoma • Usually non-Hodgkin's lymphoma: Large nodes, enlargement of Waldeyer's ring, extra lymphatic enlargement of particular glands such as the thyroid. • Hodgkin's lymphoma may be present (25%of head & neck lymphoma) particularly if there is also a mediastinal involvement.
Lymphomas can cross fascial planes easily. • Can undergo rapid enlargement. • Differential diagnosis: squamous cell cancer infectious mononucleosis.
Non-Malignant Adenopathy • Granulomatous disease: TB, sarcoid. • Fungal infections: . • Cat scratch fever. • Castleman's. • AIDS. • Post radiation changes.
Tuberculosis • Painless posterior neck mass. • Necrotic nodes particularly in level 5. • Multi-loculated with thick rim enhancement. • May calcify following treatment. • Brightly enhanced with contrast.
Infectious Mononucleosis • Multiple large non-necrotic nodes. • Enlargement of Waldeyer's ring. • Appears similar to AIDS, sarcoid, leukemia,lymphoma.
Cat Scratch Fever • Bilateral large nodes including intraparotid nodes. • Uncertain etiology ? viral or ricketsial
A I D S • Multiple small nodes. • Non-necrotic. • Enlargement of Waldeyer's ring. • Associated lympho epithelial cyst.
Sonographic features for diagnosis of cervical lymphadenopathy • Distribution Commonly involved nodal groups Mets from oropharynx, hypopharynx, larynx Internal jugular chain SubmandibularUpper cervical Mets from oral cavity Mets from nasopharyngeal carcinoma Upper cervicalPosterior triangle
Metastases from papillary carcinoma of the thyroid- Internal jugular chain • Metastases from non-head and neck carcinoma - Supraclavicular fossa Posterior triangle • Lymphoma - Submandibular, Upper cervical Posterior triangle • Tuberculosis- Supraclavicular fossa Posterior triangle
Size Shape Intranodal necrosis Echogenic hilus Echogenicity Calcification Nodal border
NECK DISSECTION • radical neck dissection, originally described by Crile • popularized by Martin et al., has been modified in various ways, giving rise to several types of cervical lymph node dissections that are currently used for the surgical treatment of the neck. • these modifications were classified according to a random system of terminology depending on the author at the time.
In 1991 the Academy’s Committee for Head and Neck Surgery and Oncology classified four major types of neck dissections:
1) Radical neck dissection; 2) Modified radical neck dissection; 3) Selective neck dissection supraomohyoid, posterolateral, Lateral anterior 4) Extended radical neck dissection.
Radical neck dissection • defined as removing all of the lymphatic tissue in regions I-V including removal of the spinal accessory nerve(SAN), sternocleidomastoid muscle (SCM) internal jugular vein (IJV).
Indications • in patients with • extensive cervical lymph node metastasis and/or extension beyond the capsule with invasion into the spinal accessory nerve, IJV, and SCM. • Many surgeons will elect to perform a RND if there is extensive disease surrounding the spinal accessory nerve without gross evidence of invasion.
Modified radical neck dissection (MRND) is defined as excision of all lymph nodes routinely removed by radical neck dissection with preservation of one or more nonlymphatic structures, i.e.,SAN, IJV, SCM. 4 Medina subclassifies the MRND into types I-III; • typeI preserves the SAN, • typeII preserves the SAN and IJV, • typeIII preserves the SAN, IJV,&SCM. type III referred to as the "functional neck dissection" (Bocca), *in his classic description the submandibular gland is not excised.
Indications • in patients with gross nodal metastasis to the neck that does not directly infiltrate or adhere to the non-lymphatic structures • Bilateral MRND is indicated when there is contralateral nodal involvement
Selective neck dissection • is defined as any type of cervical lymphadenectomy where there is preservation of one or more lymph node groups removed by the radical neck dissection. • There are four common subtypes,
Supraomohyoid neck dissection • This removes lymph tissue contained in regions I-III.
Indications • patients with primary tumors arising from the oral cavity without clinical or radiologic evidence of cervical metastasis but who have a high probability of occult lymphatic disease. • in patients with staged T2-T4N0 or TXN1 when the palpable node is less than 3 cm, clearly mobile, and located in levels I or II. • Bilateral SOHND is indicated in patients who have carcinomas of the anterior tongue or oral tongue and floor of mouth.
Posterolateral neck dissection, refers to the removal of the suboccipital lymph nodes, retroauricular lymph nodes, levels II-IV, and level V Medina suggests subclassification of the posteriolateral neck dissection to types I-III to mirror preservation of SAN, IJV, and SCM as in MRND.
Indications • This type of neck dissection is primarily used to treat the neck in patients with cutaneous malignancies and soft tissue sarcomas.
Lateral neck dissection removes lymph tissue in levels II-IV. Indications removal of nodal disease associated with carcinomas arising in the oropharynx, hypopharynx, and larynx.
Anterior neck dissection • is the last subtype of selective neck dissection and refers to the removal of lymph nodes surrounding the visceral structures of the anterior aspect of the neck
Indications • (1) selected cases of differentiated thyroid carcinoma, • (2) parathyroid carcinoma • (3) subglottic carcinoma • (4) glottic carcinomas with subglottic extension,
Extended neck dissection • defined as removal of one or more additional lymph node groups and/or nonlymphatic structures not encompassed by radical neck dissection, such as parapharyngeal, superior mediastinal, and paratracheal.
Indications • Extended neck dissections are usually performed when MRND or RND is planned for N+ necks. • The decision to extend the neck dissection may either be made preoperatively based on findings on CT or MR or intraoperatively based on findings of tumor invasion of surrounding structures. • The most significant example is when cervical disease involves the carotid artery.
Radiotherapy Along with RND when : • lymph node more than 3 cm • multiple • extra capsular invasion. • occult primary
S t e r n o m a s t o i d T u m o u r
CLINICAL FEATURES Not present at birth Appears at 20-28 days of life lump of size 1-2 cm tender in the 1st few wks of life firm in consistency smooth surface mobile sideways but not along the length of muscle
Sternomastoid shortened and tight • Restricts head movement (turned to opposite side) • No signs of inflammation • Infant otherwise well • May be associated with plagiocephaly
TREATMENT • If noticed at birth daily physiotherapy may help to prevent torticollis • If noticed only after the torticollis has developed; A brace may be used to correct the torticillis. If this fails surgery is the only option.Best technique is to divide the muscle at its proximal or distal attachment care should be taken not to injure the accessory nerve
Before surgery Tumour removed
Carotid body tumours are derived from both, the mesoderm of the second branchial arch and the ectoderm of the neural crest. • also called paragangliomas because they arise from the paraganglionic cells • malignant potential in 2.6 - 5% of the cases. • Lymphatics are the most favoured route of spread.