Case Presentation and Discussion on a

Patient with Lateral Neck Mass

Janix M. De Guzman, MD5th Year Resident

Department of Surgery

General Data:34 year-oldFemale

Chief Complaint:“lateral neck mass with difficulty of breathing”

History of the Present Illness:1 month PTA pea-sized mass, right lateral

supraclavicular area

3 weeks PTA rapid increase in sizedifficulty of breathingdifficulty in swallowinghoarsenessConsult: private hospital

1 day PTA consult at our institution – seen by ENT

- CXR, cervical APL, ECG, CBC

Referred to Surgery - Admitted

Chest X-ray

Cervical APL• No bony involvement• Visualized osseous structures intact

12 L ECG = within normal limits

CBC = Hgb = 14.1Hct = 0.46WBC = 14.2PMN = 80Lymph = 20

• Past medical history:unremarkable

• Personal and social history non-smoker

• Family medical historyunremarkable

Physical Examination:

• Conscious, speaks in phrases, oriented• BP = 90/60mmHg CR = 81beats/min

RR = 40 cycles/min Temp = 36.8OC• Pink palpebral conjuctivae, anicteric

sclerae• Symmetrical Chest Expansion, (+) stridor,

(+) retractions, intercostals• Adynamic precordium, no murmur

Physical Examination:

• Flabby Abdomen, Normoactive bowel sounds, soft, no tenderness, no organomegaly

• Extremities: no edema; full and equal pulses, no cyonosis

Physical Examination:10 x 8 cm hard mass, fixed

Non-tender

Non-erythematous

Does not moved on deglutition

(+) cervical lymphadenopathy, left

Thyroid gland not enlarged at midline.

Physical Examination:

ENT• Intact tympanic membrane, minimal

cerumen, no tragal tenderness• Tonsils - no bleeding, no discharge• Uvula in midline• Tongue midline

Salient Features• 34 y/o, female• Lateral neck mass• Stridor• Hoarseness• Dysphagia• Dyspnea

Clinical Diagnosis

A.Primary Clinical Diagnosis:Lateral Neck Mass, Right

Malignant with Airway ObstructionB.Secondary Clinical Diagnosis:

Lateral Neck Mass, RightBenign with Airway Obstruction

Lateral Neck Mass

Congenital Acquired

As suggested by history & PE:

Patient’s age = 34

Occurrence and duration of signs and symptoms = Acute

No findings of sinus or fistula

Lateral Neck Mass

Congenital Acquired

Inflammatory Non-inflammatoryMass – non-tender

No history of URTI preceding occurrence mass

No findings of on-going infection in the upper digestive tract/oral cavity

Lateral Neck Mass

Congenital Acquired

Inflammatory Non-inflammatory

Benign MalignantConsistency = Hard, fixed mass

Invasive/Aggressive = associated dysphagia, dyspnea, hoarseness

Difficulty of Breathing

Cardiac/ Circulatory

Perfusion

Respiratory/Ventilation

As suggested by History & PE:

No history of cardiac problems

Normal Cardiac findings on physical examination.

Pink palpebral conjunctivae.

Difficulty of Breathing

Cardiac/ Circulatory

Perfusion

Respiratory/Ventilation

Upper/Airway Lower/LungPE finding of stridor

Difficulty of Breathing

Cardiac/ Circulatory

Perfusion

Respiratory/Ventilation

Upper/Airway Lower/Lung

Non-Inflammatory/Non-Infectious Inflammatory/Infectious

No history of upper respiratory tract infection/asthma

History of rapidly enlarging mass on neck area.

Difficulty of Breathing

Cardiac/ Circulatory

Perfusion

Respiratory/Ventilation

Upper/Airway Lower/Lung

Non-Inflammatory/Non-Infectious Inflammatory/Infectious

Malignant BenignBy pattern and prevalence a malignant condition is more likely the cause of dyspnea on this patient.

Airway Management

(invasive)

20%Lateral Neck Mass, Right, Benign with Airway Obstruction

Airway Management

(invasive)

80%Lateral Neck Mass, Right, Malignant with Airway Obstruction

TREATMENTMODALITY

CERTAINTYCLINICAL DIAGNOSIS

Paraclinical Diagnostic Procedures

• Do I need additional paraclinical diagnostic procedure?

– NO.– Patient in severe respiratory distress.– Can not tolerate additional para-clinical

diagnostic procedures.

Treatment

Pre-treament Diagnosis:

Lateral Neck Mass, RightMalignant

Airway Obstruction

Treatment

• Goal of Treatment:> provide adequate

ventilation/oxygenation

Treatment Options

Yes5TBleedingPneumothoraxPneumomediastinum

Able to by-pass obstruction and provide adequate ventilationRelatively well-tolerated by alert patientsProvide long term access

Tracheostomy

Yes5TDamage to cricoidcartilagePerichondritis/Stenosis

Readily accessible Short term intervention

Cricothyrotomy

Yes2HMucosal irritationNeeds repeated suctioningTracheal stenosisTracheomalaciaErosion/fistula formation with Esophagus or innominate artery

Can provide adequate ventilationRelative CI –obstruction(inability to insert)Not tolerated by alert patients

EndotrachealIntubation

Availability

CostRiskBenefitTreatment

Endotracheal Intubation

Cricothyrotomy

Tracheostomy

Preoperative preparation:• Informed consent secured• Psychosocial support• Optimize patient’s health• Screen for any condition that will interfere with

treatment– As with any emergent procedure, the decision to

perform an emergent tracheostomy is not altered by any lab values

• Prepare materials

Operative Technique• Position: supine with neck extended• Local anesthesia injected subcutaneously• Incision: transverse incision, 1-2 cm above

sternal notch, long enough to facilitate the safe performance of tracheostomy, usually between the two sternocleidomastoid muscles

• Flap formation, up and down, to expose the lower strap muscles

• Strap muscles split and retracted at vertical midline

Operative Technique• Exposure the trachea below the thyroid isthmus

(if there is an isthmus)• Complete hemostasis before creating an

opening in the trachea• Prepare to remove the endotracheal tube if it is

there• Get ready to suction secretions upon opening of

trachea• Create an opening on the trachea (below

isthmus) - cruciate (+) incision

Intra-operative Findings

• Trachea deviated to the left• Smooth mucosal surface upon opening • No mass intraluminally.• Thyroid Gland grossly normal.

Operative Technique

• Insert tracheostomy tube (proper size and type)

• Check proper placement of tube inside trachea – air going in and out the trachtube during respiration

• Suction secretions• Anchor tube with cloth tapes

Operative Technique

• Recheck hemostasis• Correct instrument and sponge count• No need to appose strap muscles at

midline• No need to suture skin incision• Dressing around the tube and over the

incision site

Operative Technique

• Perioperative tips– Avoid iatrogenic complications – bleeding

(injuring the big vessels at the neck), transecting the trachea, injuring the esophagus, rupturing apex of lung, etc.

– Avoid long term complication of stenosis• Removing part of the trachea is more prone to

stenosis, thus cruciate incision is preferred.

Lateral Neck Mass, RightMalignant

Need for para-clinical diagnostic procedure – YES.Goal:

> establish a definite diagnosis.

Biopsy Options

Yes450HematomaSensitivity 96%Specificity 89%Accuracy 92%58% treated conservatively

Core-needle biopsy

Yes600BleedingInjury to

surrounding structures

100% accuracy2-3x increased incidence of local treatment failure

Incision Biopsy

Yes300minimalSensitivity & Specificity> 90% Low to absent seeding

FNABAvailabilityCostRiskBenefitTreatment

Incision Biopsy done:Considered for neck masses:

with progressive growth, location within the supraclavicular fossasize greater than 3 cm. if a patient with a neck mass develops symptoms associated with lymphoma

*Frozen-section examination of the mass followed by neck dissection should be performed if the mass proves to be metastatic carcinoma.

Operative procedure done:

Tracheostomy under localIncision Biopsy under local

Post operative Diagnosis

Lateral neck mass, RightMalignant

With Airway Obstruction

Discussion:

• Explain patient’s condition and possible disease entities to patient herself and relative/s.

• Follow – up histopathology result.• Instructions on tracheostomy care.

Neck Mass

Skin LymphaticsSoft Tissue Aero-digestive tractGlands

Lateral Neck Mass

Skin LymphaticsSoft Tissue Aero-digestive tractGlands

Lateral Neck Mass

Skin LymphaticsSoft Tissue Aero-digestive tractGlands∅Deep location

Lateral Neck Mass

Skin LymphaticsSoft Tissue Aero-digestive tractGlands∅Thyroid Malignancy

PrimarySecondary

Anaplastic Carcinoma

Sarcoma

Lymphoma

• As General Rule: (excerpts from General Management Guidelines of Neck Tumors)

• As to the pathology– By pattern recognition the signs and

symptoms on this patient points more to a malignant process:

• Rapidly growing mass• Hard, fixed mass• Highly invasive – dysphagia, hoarseness, dyspnea

• As General Rule: (excerpts from General Management Guidelines of Neck Tumors)

• As to the origin (prevalence recognition)– Lateral anterior neck tumors are

commonly enlarged lymph nodes– Metastatic or secondary neck

malignancies more common than primary neck malignancies at all ages.

Clinical Diagnosis – pending histopath result

CertaintyPathology

25LymphomaTertiary

35Soft Tissue Sarcoma

Secondary

40AnaplasticThyroid

Carcinoma

Primary

Anaplastic Carcinoma of the Thyroid

• Although apparently clinically normal thyroid gland on initial evaluation – a lateral neck mass can be the sole presenting sign

• 1 to 5 % - of all thyroid cancers in the U.S. each year

• The symptoms of anaplastic cancer include: – A mass in the neck (thyroid area), often rapidly

enlarged – Hoarseness or a change in the voice – Difficulty of breathing– Difficulty swallowing

Anaplastic Carcinoma of the Thyroid

• prognosis very poor• less than 5% of patients survive 5 years• an estimated 10% of patients are alive at 3 years• Most people do not survive longer than 6

months• 80% do not survive beyond a year

Soft Tissue Sarcoma

• tumors that can develop from fat, muscle, nerve, joint, blood vessel, or deep skin tissues (mesenchymaltissues)

• Rare, comprise 1% of all carcinoma, – 5% affects head and neck region

• Invades surrounding tissue and metastasize to other organs

• Risk Factors:– Exposure to herbicides, radiation– Infection with retrovirus– Genetic predisposition

Lymphoma

• Hodgkin’s – type of cancer that develops in the lymph system, part

of the body's immune system. – Lymph System:

• Lymph• Lymph vessels• Lymph nodes• Spleen• Thymus• Tonsils• Bone marrow

Lymphoma• Risk factors for adult Hodgkin's lymphoma

include the following:– Being in young or late adulthood. – Being male. – Being infected with the Epstein-Barr virus– Having a first-degree relative (parent, brother, or

sister) with Hodgkin's lymphoma. • Possible signs of adult Hodgkin's lymphoma

include:– swollen lymph nodes– fever– night sweats– weight loss

Lymphoma

• Hodgkin’s – 5 different types– Nodular sclerosing Hodgkin's lymphoma. – Mixed cellularity Hodgkin's lymphoma. – Lymphocyte depletion Hodgkin's lymphoma. – Lymphocyte-rich classical Hodgkin's lymphoma. – Nodular lymphocyte-predominant Hodgkin's

lymphoma

Lymphoma

• Non-Hodgkin lymphoma (non-Hodgkin’s lymphoma, or NHL) is cancer, sometimes called lymphoma, that starts in lymphoid tissue (also called lymphatic tissue), which is part of the lymphatic system

• Lymphomas start from lymphocytes in either the lymphoid tissue or lymphoid organs and can spread from there.

• All other types of lymphoma are called non-Hodgkin lymphomas.

Tracheostomy Care

• What the patient/relatives should know– Tracheostomy – a tube is inserted to keep

windpipe open and supply with air. Indicated to by-pass airway obstruction.

– a small opening called a stoma is created through the skin on your throat, to be able to inserts a breathing tube directly into the windpipe (trachea).

Tracheostomy Care

• What the patient/relatives should know– Three parts:

• Obturator• Outer cannula (tube) with trach plate

– Trach plate lies agains the skin, it can be sewn to skin or held with trach ties

– Some tubes have inflatable cuff near outer end to keep from coming out and prevent air leaks

• Inner cannula

Tracheostomy Care

• What the patient/relatives should do– Cleaning the inner cannula

• Can take out the inner cannula by gently pulling it out and downwards. Clean on daily basis by soaking it on soap and water, brushing and rinsing thoroughly.

Tracheostomy Care• What the patient/relatives should do

– Suctioning the Tube• Suction the tube of clogged mucus if unable to

cough it out• Using a suction tip attached to a machine

– Take a few deep breaths– Insert wet suction tip 5 to 8 inches. Do not cover

catheter’s control valve– Pull it out slowly, back and forth, cover and uncover

control valve. Do not cover valve for more than ten seconds at a time.

• Bulb syringe can be used.

Tracheostomy Care• What the patient/relatives should do

– Don't be afraid if you cough out the trach tube.You can put it back in with the following steps:

• First use a syringe to take the air out of the cuff on the innercannula, then remove it from the outer cannula. Put the obturator into the outer cannula.

• Insert the obturator and outer cannula through your stoma. Pull out the obturator while pressing the trach plate firmly against your neck.

• Put the inner cannula down the outer cannula and turn it clockwise until it locks in place. Inserting the inner cannulacan make you cough or gag, so hold the trach plate firmly. Now inflate the cuff so the trach won't fall out again. Tie the trach ties and put a trach bib under the trach plate.

Tracheostomy Care• Call Your Doctor If...

– You still have trouble breathing after coughing or suctioning.

– Your stoma looks swollen or red, or you see pus coming out of it or the area around it. These are signs of infection.

– You run a high temperature.

Tracheostomy Care• Seek Care Immediately If...

– You are very short of breath and coughing or suctioning doesn't help.

– Your trach falls out and you can't get it back in. Call assistance to get to the nearest hospital or clinic.

References:

• Callanan V, O'Connor A F F. Adult and paediatrictracheostomy - technique, complications and alternatives. Curr Pract Surg 1994; 6: 219-22.

• Shaha A, Webber C, Marti J. Fine-needle aspiration in the diagnosis of cervical lymphadenopathy. Am J Surg1986;152:420-3.

• Screaton N, Berman L, Grant J. US-guided Core-Needle Biopsy of the Thyroid Gland. Radiology 2003;226:827-832

• Mighell AJ, High AS. Histological identification of carcinoma in 21 gauge needle tracks after fine needle aspiration biopsy of head and neck carcinoma. J ClinPathol 1998;51:241-3.

References:• Schwetschenau E, Kelley D. The Adult Neck Mass.

Am Fam Physician 2002;66:831-8

• Gleeson M, Herbert A, Richards A. Management oflateral neck masses in adults. BMJ 2000;320:1521-1524

• Maceri DR, Babyak J, Ossakow SJ. Lateral neck mass. Sole presenting sign of metastatic thyroid cancer. Arch Otolaryngol Head Neck Surg. 1986;112(1):47-9.

Coleman SC, Smith JC, Burkey BB, Day TA, Page RN, Netterville JL. Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma. Laryngoscope. 2000;110:204-9.

MCQDirection: Choose the best answer.

1. Which of the following is associated with Epstein-Barr virus?a. Chronic Lymphocytic Leukemiab. Burkitt Lymphomac. Mantle cell Lymphomad. Hodgkin’s Lymphomae. Small lymphocytic lymphoma

MCQ

Direction: Choose the best answer.

1. Cancer associated with Epstein-Barr virus.a. Chronic Lymphocytic Leukemiab. Burkitt Lymphomac. Mantle cell Lymphomad. Hodgkin’s Lymphomae. Small lymphocytic lymphoma

2. Obstruction in the upper respiratory airway would produce this breath sound.

A. cracklesB. vesicular soundsC. stertorD. bronchial soundsE. stridor

2. Obstruction in the upper respiratory airway would produce this breath sound.

A. cracklesB. vesicular soundsC. stertorD. bronchial soundsE. stridor

MCR.

Direction: Write“A” if 1, 2, and 3 are valid statements.“B” if only 1 and 3 are valid statements.“C” if only 2 and 4 are valid statements.“D” if only 4 is a valid statement.“E” if all are valid statements.

3. Malignant neoplasms of the neck would cause:

1. Central nervous system invasion2. malnutrition3. Upper airway obstruction4. Recurrent aspiration pneumonia

3. Malignant neoplasms of the neck would cause:

1. Central nervous system invasion2. malnutrition3. Upper airway obstruction4. Recurrent aspiration pneumonia

4. Late complications of tracheostomy:

1. tracheomalacia2. bleeding3. stenosis4. tracheitis

4. Late complications of tracheostomy:

1. tracheomalacia2. bleeding3. stenosis4. tracheitis

5. Generally the lymph system is made up of the following?

1. lymph2. tonsils3. spleen 4. bone marrow

5. Generally the lymph system is made up of the following?

1. lymph2. tonsils3. spleen 4. bone marrow