Page 1018 - TNFlipTest

OT32 Otolaryngology
Congenital Neck Masses
Toronto Notes 2019
• granulomatousdisease
■ mycobacterial infections ■ sarcoidosis
• neoplastic
■ lymphoma
■ salivary gland tumours
■ thyroid tumours
■ metastatic malignancy (“unknown primary”)
■ lipoma, fibroma, hemangioma, nerve or nerve sheath tumour
Evaluation
Investigations
• historyandphysical(includingnasopharynxandlarynx)
Inflammatory vs. Malignant Neck Masses
• •
• • •
all other investigations and imaging are dependent upon clinical suspicion following history and physical
laboratoryinvestigations
■ WBC: infection vs. lymphoma ■ Mantoux TB test
■ thyroid function tests and scan
imaging
■ neck U/S
■ CTscan
■ angiography: vascularity and blood supply to mass
biopsy for histologic examination ■ FNA: least invasive
■ needle biopsy
■ open biopsy for lymphoma
identificationofpossibleprimarytumour(ruleoutametastaticlymphnodefromanunknown primary)
■ panendoscopy: nasopharyngoscopy, laryngoscopy, esophagoscopy, bronchoscopy with washings, and biopsy of suspicious lesions
■ biopsy of normal tissue of nasopharynx, tonsils, base of tongue, and hypopharynx
■ primary identified 95% of time → stage and treat
■ primary occult 5% of time: excisional biopsy of node for histologic diagnosis → manage with
radiotherapy and/or neck dissection (squamous cell carcinoma)
Congenital Neck Masses
Brachial Cleft Cysts/Sinuses/Fistulae
Inflammatory Neoplastic
History
Painful Y
H&N infection Y
Fever Y Weight loss N
CA risk factors N
Age Younger
Physical
Tender Y Rubbery Y Rock hard N Mobile Y
N
N
N
Y
Y Older
N Occipital Y
± fixed
Embryology
• atthe6thwkofdevelopment,the2ndbranchialarchgrowsoverthe3rdand4tharchesandfuseswith the neighbouring caudal pre-cardial swelling, forming the cervical sinus
• 3typesofmalformations
1. branchial fistula: persistent communication between skin and GI tract 2. branchial sinus: blind-ended tract opening to skin
3. branchial cyst: persistent cervical sinus with no external opening
Clinical Features
• 2ndbranchialcleftmalformationsmostcommon
■ sinuses and fistulae present in infancy as a small opening anterior to the sternocleidomastoid muscle ■ cysts present as a smooth, painless, slowly enlarging lateral neck mass, often following a URTI
• 1stbranchialcleftmalformationspresentassinus/fistulaorcystinpreauricularareaoronfaceover angle of mandible
• 3rdbranchialcleftmalformationspresentasrecurrentthyroiditisorthyroidabscessandhavea tract which usually leads to the left pyriform sinus. Air on CT scan in or near the thyroid gland is pathognomonic for this anomaly
• thereiscontroversywhether4thbranchialcleftanomaliesexist,astheymayberemnantsofthe thyrothymic axis
Treatment
• surgicalremovalofcystorfistulatract
• ifinfected:allowinfectiontosettlebeforeremoval(antibioticsmayberequired)