ProblemProblem-base learning

Neck Mass

Case
Case :

40

.
4

Chief Complaint :

Present illness


    

4 PTA

Past history

More History ?


      

Physical examination

Physical examination
 

GA : A thai female, good consciousness,

not pale,no jaundice

Vital signs :
BT = 37.2 0C 37. RR = 16/min 16/min BP = 120/80 mmHg 120/ PR = 84 bpm

 

Heart & lung : normal Abdomen : liver and spleen cant be

palpated

ENT exam
Nose : normal Nasopharynx : no polyp , no mass seen,
no discharge, not injected, not swelling

Oropharynx : tonsil arent enlarged, dental caries,

no ulcer, not injected ,no swelling ,no

IDL

: vocal cord normal movement, no nodule , not injected

Neck Examination
  

Thyroid gland not enlargement Parotid gland normal Neck mass: (more info next slide)

Positive finding
Hx: Hx:  4 PTA    

Positive finding


PE.
Neck mass : At posterior triangle, irregular surface, firm, not tender, movable, no sign of inflammation, no translucency

Mass :
- posterior triangle - irregular surface - firm - not tender - movable - no sign of inflammation - no translucency

Approach to neck mass

Etiology
    

Congenital Trauma Tumor Infection,inflammation Miscellaneous : Anatomical variation

Neck mass
     

Incidence Age Sex Duration (Rule of seven) Pain General symptoms

Etiology
0-15 years Inflammatory Congenital developmental Neoplasmmalignant Benign 16-40 years Inflammatory Congenital developmental Neoplasm-benign Malignant >40 years Malignant Benign

Inflammatory Congenital developmental

Rule of 80s 80s



Older than 40 years old

80% of all nonthyroid neck masses are neoplastic 80%  80% of these neoplasms are malignant 80%  80% of these malignant lesions are metastatic lesions 80%  80% of these metastatic lesions arise from primaries 80% that are above the clavicle


Medical Student Gr. 5A

History of cancer


    

, , , 4- 6

Physical examination
  

Local examination Regional examination General examination

Local examination
       

Location (midline or lateral) Size Shape Surface Consistency Tenderness Mobility Pulsation

Midline mass
      

Thyroglossal duct cyst Isthmus of thyroid Pharyngeal pouch Subhyoid bursa Delphian node Laryngocele Ectopic thyroid

Lateral neck mass

 

NonNon-lymph node Lymph node

NonNon-lymph node
      

Solitary thyroid nodule Branchial cleft anomalies Cystic hygroma Carotid body tumor Lipoma Neurilemmoma Swelling of salivary gland

Lymph node


Infection -acute (pyogenic) -chronic (Tuberculosis,atypical mycobacterium,cat scrath fever) Primary neoplasm - Hodgkins lymphoma - Non-Hodgkins Non-

Lymph node


Metastatic node - Head and neck cancer - Below clavicular cancer (lung,GI,etc.) (lung,GI,etc.) - Unknown primary

Lymph node drainage

Cervical node region and possible origin of primary neoplasm Lymph node
Submandibular Posterior cervical Supraclavicular Upper jugular Middlejugular Low jugular

Primary
Lower lip,floor of mouth,tongue (anterior),Tonsil,buccal mucosa,gingiva Nasopharynx,thyroid,lateral pharyngeal wall Below the clavicle Tongue(lateral and posterior),palate,tonsil Pharynx,larynx,piriform sinus,thyroid Esophagus (cervical segment)

Investigation
    

CBC Chest X-ray XFlexible rhinolaryngoscope, nasopharyngoscope rhinolaryngoscope, Ultrasonography Direct laryngoscope,bronchoscope, laryngoscope,bronchoscope, esophagoscope

Investigation
   

Fine needle aspiration Sialography,MRI Biopsy Syphilis,AIDS

Diffential diagnosis
 

Diffential diagnosis
   

Lymphoma ( primary neoplasm ) Tuberculous lymphadenitis Metastatic lymph node neoplasm Lipoma

lymphoma NonNon-hodgkins
     

Progressive clonal expansion B-cell , T-cell , NK BTm/c hematopoietic neoplasm ( 5 times of HD ) Painless adenopathy , fatigue and weakness B symptoms : fever , night sweat , lost weight Hepatosplenomegaly Noncontiguous pattern of spreading

Hodgkins disease
   

Predominant B-cell malinancy BBimodal age distribution : 3rd decade , around 60 Common present with cervical adenopathy B symptom , pruritis , hepatosplenomegaly , Pel Ebstein fever , Alcohol-induced pain ( rare Alcoholbut hign specificity ) contiguous pattern of spreading

Tuberculous lymphadenitis


m/c site : neck along the sternocleidomastoid m. , posterior cervical and supraclavicular sites. The most common presentation of extrapulmonary tuberculosis Painless , Advanced may suppurate and form a drainage particularly frequent among HIV-infected HIVpatients

lipoma
      

Benign All age m/c adult Soft , not tender slippery , not attach to skin Vary of size Solitary nodule is common Treatment : conservative except tender or rapid growth ( Sx common for cosmetics ) , liposuction recurrent

Investigation


investigate

Investigation
  

CBC Chest X ray FNAB

CBC
  

Hb 11.9 g/dL , Hct 34.3% 11. 34. WBC count 9,500 /L WBC differential
   

Neutrophil 63 % Lymphocyte 32 % Atypical Lymphocyte 2% Monocyte 2 %

  

RBC 5.3 x 106 / L Pletelet 350,000 / L 350, Normocytic normochromic RBC

Chest X-ray X-

FNA


 

Moderate amount of small mature lymphocyte A few plasma cell No evidence of malignancy seen

Manageme nt

Neck mass

Hx & PE ENT exam

+
Biopsy

CXR CBC FNA

PF

Panendoscope Biopsy 4-5 points + Nasopharynx exam , biopsy

BOT Supraglottis Tonsils

Panendoscope Biopsy 4-5 points + Nasopharynx exam , biopsy

Unknown 10

Open biopsy + frozen Section + Radical neck dissection , chemo

Management
Management next
Excisional biopsy

Excisional biopsy

Pathology finding : 4x

Pathology finding : 10x 10x

Pathology finding 40x

Pathology finding 40x 40x

Whats definite diagnosis?

Tuberculous lymphadenitis

Treatment
  

Anti TB drugs Supportive treatment education

The End . Thank for your attention

Question


1. neck mass

midline lateral neck mass 3

2. (

neck mass congenital,infection,trauma,tumor

Question


3.

malignancy

4.Investigation

5. excisional biopsy primary lesion

malignancy biopsy