mouth oral &

face maxillofacial

jaws head & neck

neck surgery

Management of Neck Lumps

Mr Ceri Hughes BDS, FDSRCS, MBChB, FRCS(OMFS), FRACDS (OMS)

Consultant Oral & Maxillofacial / Head and Neck Surgeon Head & Neck MDT Lead

University Hospitals Bristol

Learning objectives

• Classification of neck lumps

• Relevant anatomy and descriptive terms

• Relevant investigations (primary care + 2nd)

• Surgical sieve, provisional diagnosis

• Clinical examples

• Quiz

Broad classification

Neck lump

Benign Malignant

NECK

LUMP

Benign

Lymphoid Thyroid Salivary Infection Congenital

NECK

LUMP

Malignant

Lymphoma Salivary Thyroid Metastatic

Diagnostic pathway

• History

• LOCAL examination

• REGIONAL (NECK) examination

• GENERAL examination

• Provisional diagnosis

• Special tests

• Tipping point, to refer or not

REGIONAL

Useful to think in terms of

MIDLINE & LATERAL LUMPS

LATERAL

MIDLINE

THINK, what structures are there?

• Skin

• Fat

• Muscle

• Blood vessels

• Lymph nodes

• Salivary (parotid, submandibular)

• Thyroid

LATERAL

MIDLINE

Clinical examination

• Position patient

Clinical examination

• Ring

– Sub mental

– Sub mandibular

– Parotid

– Posterior auricular

– Occipital

Clinical examination

• Rod

– Deep jugular

– Level II/III/IV/V

– Anterior triangle

– Post triangle

Clinical examination

• Rod

– Deep jugular

– Level II/III/IV/V

– Anterior triangle

– Posterior triangle

Description of neck disease

Anterior/posterior Level I-VI

TNM STAGING

INVESTIGATIONS

• BLOOD

• RADIOLOGICAL

• MICROBIOLOGY

• SEROLOGY

• CYTOLOGY

• HISTOLOGY

BLOOD

• FULL BLOOD COUNT & DIFF

• U&E, LFT

• SPECIFIC ANTIBODIES

• THYROID FUNCTION

RADIOLOGY • PLAIN

• ULTRASOUND (USS)

• SIALOGRAPHY

• CT (computerised tomography)

• MRI (magnetic resonance imaging)

• ISOTOPE

• PET (positron emission tomography)

RADIOLOGY • PLAIN

• USS

RADIOLOGY

cystic

Micro calcification

RADIOLOGY

• SIALOGRAPHY

RADIOLOGY • CT

RADIOLOGY • MRI

RADIOLOGY • ISOTOPE

RADIOLOGY • PET

MICROBIOLOGY

• Swab

• Pus

• Tissue

• For MC&S (microscopy, culture and sensitivity) TB, Actinomycosis

• Quantiferon

CYTOLOGY & HISTOLOGY

• FINE NEEDLE ASPIRATION (cytology/culture)

• FLOW CYTOMETRY

• TRUCUT (increasing especially in lymphoma)

• CELL BLOCKS (centrifuged needle washings)

• IMPRINT CYTOLOGY (from biopsy)

• OPEN BIOPSY

• RESECTION

FNA

USS + FNA

Thyroid cytology

• Th1 (inadequate)

• Th2 (benign)

• Th3 (follicular lesion 3a or 3f)

• Th4 (suspicious for malignancy)

• Th5 (malignant)

RADIOLOGY • ELASOTOGRAPHY

Thyroid Decision making

• Clinical

• Ultrasound (U)

• Cytology (Th)

• Elastography

• Patient preference

HISTOLOGY

CLASSIFICATION (neck pathology)

Surgical sieve

Congenital Aquired

CONGENITAL

– LYMPHANGIOMA

– DERMOID CYSTS

– THYROGLOSSAL CYSTS

– BRANCHIAL CYSTS

– PHARYNGEAL POUCH

AQUIRED

• TRAUMATIC

• INFECTIVE

• INFLAMMATORY

• IATROGENIC

• NEOPLASTIC

• METABOLIC

• AUTOIMMUNE

• NO IDEA

TRAUMATIC

• HAEMATOMA

• DISSECTION

• AIR EMPHYSEMA

INFECTIVE

• DENTAL INFECTION

• NECK SPACE INFECTIONS

• EBV

• CAT SCRATCH DISEASE

• TOXOPLASMA

• TB

• CMV

• HIV (PGL)

INFECTIVE

• DENTAL INFECTION

• NECK SPACE INFECTIONS

INFECTIVE

• REACTIVE NODES

• TOXOPLASMOSIS

• CAT SCRATCH

• CMV

• EBV

INFLAMMATORY

• SIALADENITIS (GUSTATORY)

• SARCOIDOSIS

• RHEUMATOID (FELTYS )

METABOLIC

AUTOIMMUNE

NEOPLASTIC

• BENIGN

• MALIGNANT

–PRIMARY

–METASTATIC

NEOPLASTIC

• BENIGN

NEOPLASTIC

• MALIGNANT

–PRIMARY

–METASTATIC

NEOPLASTIC

• MALIGNANT

–PRIMARY

–METASTATIC

QUIZ

• RED FLAGS

– Rapid growth

– Effect on adjacent structures

• Nerves (facial, recurrent laryngeal), skin, airway

– Risk factors

Age, smoking, radiation, FH, previous

– Systemic symptoms such as wt loss, B sypmtoms

Questions

ceri.hughes@uhbristol.nhs.uk

Louise.parkes@uhbristol.nhs.uk

claire.roberts3@spirehealthcare.com

Oral cavity malignancy

Mr Ceri Hughes FDSRCS, FRCS(OMFS)

Consultant Oral & Maxillofacial / Head and Neck Surgeon University Hospitals Bristol

Aims

• Understand classification of tumour sites

• Become familiar with clinical examples

• Be aware of referral triggers

Oral cavity

• Vermillion skin junction of lip to junction of hard and soft palate above and to circumvallate papillae below

• Mucosal lip

• Buccal mucosa

• Lower alveolar ridge

• Upper alveolar ridge

• Retromolar trigone

• Floor mouth

• Hard palate

• Anterior 2/3 tongue

Presentation of oral cancer

• ulcer

• white or red patches

• mass

• pain

• bleeding

• tooth mobility

• neck lump

Red flags

• White/red patches (that have changed)

• Induration

• Bleeding

• Rapid increase in size

• Earache

• Necrosis especially with odour

Case discussions