Head and Neck Case Studies

Transcription

1 Head and Neck Case Studies John Chaplin & Nick McIvor Head and Neck

2 lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis

3 lumps factors to consider age & duration tissue & site number auckland head & neck associates

4 lumps factors to consider age & duration Congenital Inflammatory Benign neop Malign neop 0 < >40 auckland head & neck associates

5 lumps factors to consider age & duration tissue & site auckland head & neck associates

6 lumps factors to consider age & duration tissue & site number auckland head & neck associates

7 FNA pulsatile mass non diagnostic aspirate sites US guided FNA

8 pulsatile mass & bleeding usually FNA not necessary or advisable (bruising only) diagnosis aneurysmal artery tortuous artery Cf elderly carotid body tumour

9 non-diagnostic aspirate solid vs cystic

10 evolution of metastasis

11 evolution of metastasis

12 evolution of metastasis subcortical

13 evolution of metastasis subcortical

14 evolution of metastasis hilar effacement

15 evolution of metastasis nodal rounding?palpable

16 evolution of metastasis extranodal extension

17 thyroid nodules Bethesda system % malig 1. Non diagnostic 5 2. Benign 3 3. Follicular undetermined Follicular neoplasm Suspicious malig Malignant 100

18 non-diagnostic and benign Reason Cystic Complex Bloody Multiple Plan Repeat USGFNA

19 USFNA

20 ultrasound in FNA thyroid nodule posterior nodule partially cystic multiple suspicious features microcalcification internal vascularity hypoechoic irregular halo taller than wide on transverse view

21 parotid gland adenoma metastatic node adenocarcinoma

22 parotid gland Mixed cellular population with myxoid stroma pleomorphic adenoma

23 parotid gland Mixed cellular population with myxoid stroma pleomorphic adenoma 95% accuracy Continue to grow Potential malignant change

24

25 submandibular whole gland Fluctuating stable lump within gland adenoma adencarcinoma lump outside gland node reactive lymphoma metastatic

26 lymphoid aspirate suggests reactive lymphadenopathy monoclonal population can not be excluded.. assess in clinical context.

27 lymphoid aspirate suggests reactive lymphadenopathy monoclonal population can not be excluded.. assess in clinical context.

28 lymphoid aspirate If obvious source of inflammation- treat and observe If node is large (>3cm) remove to exclude lymphoma If no obvious source Blood screen: FBC, Toxoplasmosis, EBV, cat scratch disease, CMV. Observe over one to two months and if still present or larger remove to exclude lymphoma Continue to observe if smaller

29 USFNA - equipment Needle- 22 gauge Syringe - 5ml Glass slides Pencil Pottle Saline Band-aid Ultrasound (optional)

30 technique Multiple passes

31 USFNA neck mass partially necrotic suspicious features aspirate for assay Thyroglobulin Calcitonin Parathyroid Hormone

32 lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis

33 Q1 Most likely head and neck mucosal cancer to present to a GP? 1. Oral cavity 2. Tonsil and base of tongue 3. Nasopharynx 4. Larynx 5. pharynx

34 Q1 Most likely head and neck mucosal cancer to present to a GP? 1. Oral cavity 2. Tonsil and base of tongue 3. Nasopharynx 4. Larynx 5. pharynx Answer: 2. tonsil and base of tongue

35 Q2 Case 1 45 yr old male Never smoked 3 week history right neck mass No pain No cutaneous malignancy No pharyngeal symptoms Head and Neck

36 Q2 Most approp test a. Oral cavity exam b. Flexible endoscopy c. FNA d. skin examination e. All of the above Head and Neck

37 Q2 Most approp test a. Oral cavity exam b. Flexible endoscopy c. FNA d. skin examination e. All of the above e. All these are appropriate Head and Neck

38 Q3 FNA shows fluid with mild atypical epithelial cells. Pathologist suggests excision of mass. Do you? a. Refer for excision b. Send to another pathologist for repeat FNA c. Send patient away with no follow up d. Refer for upper airway exam and biopsy of potential primary sites d.need to rule out a cystic metastases from upper airway SCC Head and Neck

39 Q4 What is the most common presentation of tonsil cancer? 1. sore ear +/or sore throat 2. Blood in saliva 3. Swallowing difficulty or pain 4. Neck lump 5. Worsening snoring or OSA

40 Q4 What is the most common presentation of tonsil cancer? 1. sore ear +/or sore throat 2. Blood in saliva 3. Swallowing difficulty or pain 4. Neck lump 5. Worsening snoring or OSA answer: 4. neck lump

41 Q5 Most common neck node involved in oropharyngeal cancer? 1. submandibular 2. Parotid 3. upper lateral neck 4. Lower lateral neck 5. Posterior triangle

42 Q5 Most common neck node involved in oropharyngeal cancer? 1. submandibular 2. Parotid 3. upper lateral neck 4. Lower lateral neck 5. Posterior triangle Answer: 3. upper lateral neck

43 Q6 40 yr old man - nonsmoker 2cm upper lateral neck lump 1 month - asymptomatic What is the appropriate action? 1. Exam skin 2. Examine oral cavity and tonsils 3. FNA and serology 4. Refer for upper airway endoscopy 5. All of the above

44 Q6 40 yr old man - nonsmoker 2cm upper lateral neck lump 1 month - asymptomatic What is the appropriate action? 1. Exam skin 2. Examine oral cavity and tonsils 3. FNA and serology 4. Refer for upper airway endoscopy 5. All of the above Answer: 5. all of the above

45 Q7 Most common cause of tonsil/base of tongue cancer? 1. Smoking 2. alcohol 3. Smoking and alcohol 4. EBV 5. Oral sex

46 Q7 Most common cause of tonsil/base of tongue cancer? 1. Smoking 2. alcohol 3. Smoking and alcohol 4. EBV 5. Oral sex Answer: 5. oral sex

47 Q8 Overall cure rate for tonsil/base of tongue cancer? 1. 0% 2. 25% 3. 50% 4. 75% %

48 Q8 Overall cure rate for tonsil/base of tongue cancer? 1. 0% 2. 25% 3. 50% 4. 75% % Answer: 4. 75%

49 Q9 What is the NZ HPV vaccination schedule? 1. There is none 2. Vaccinate girls Vaccinate girls and boys Vaccinate females Vaccinate both sexes 11-26

50 Q9 What is the NZ HPV vaccination schedule? 1. There is none 2. Vaccinate girls Vaccinate girls and boys Vaccinate females Vaccinate both sexes Answer: 2. vaccinate girls 11-12

51 Q10 Case 2 40 year old male 1 month submental/submandib lumps healthy oral cavity and skin

52 Q10 Case 2 most likely diagnosis? 1. acne 2. tonsillitis 3. Glandular fever 4. toxoplasmosis 5. lymphoma

53 Q10 Case 3 most likely diagnosis? 1. acne 2. tonsillitis 3. Glandular fever 4. toxoplasmosis 5. lymphoma Answer: toxoplasmosis but you must prove it

54 Q11 Case 3 50 yr old man Hard mass low right neck CT as shown FNA mass suggests benign thyroid follicular cells Head and Neck

55 Q11 Case 3 50 yr old man Hard mass low right neck CT as shown FNA mass suggests benign thyroid follicular cells Level IV neck mass Thyroid cyst Head and Neck

56 Q11 Case 3 What is this most likely to be. a. metastatic thyroid cancer b. missed biopsy (thyroid cyst) c. lateral aberrant thyroid tissue d. pathologist error Head and Neck

57 Q11 Case 3 What is this most likely to be. a. metastatic thyroid cancer b. missed biopsy (thyroid cyst) c. lateral aberrant thyroid tissue d. pathologist error a. Metastatic thyroid cancer Head and Neck

58 Q11 Case 3 Papillary cancer is well differentiated and cells can look benign. Mass wont elevate like thyroid even though in same position Head and Neck

59 Q12 Case 4 29 yr old man 6 months lump angle of jaw No pain, tenderness Head and Neck

60 Q12 Angle of jaw lump What is this most likely to be a. Pleomorphic adenoma b. Metastatic skin cancer c. Mumps d. Acinic cell cancer Head and Neck

61 Q12 Angle of jaw lump What is this most likely to be a. Pleomorphic adenoma b. Metastatic skin cancer c. Mumps d. Acinic cell cancer a. Pleomorphic adenoma: benign salivary tumour Head and Neck

62 Q13 Patient presents with parotid mass and this facial examination. What is most likely tumour. a. Adenoma b. Carcinoma c. Schwannoma Head and Neck

63 Q13 Answer: b carcinoma Patient presents with parotid mass and this facial examination. What is most likely tumour. a. Adenoma b. Carcinoma c. Schwannoma Head and Neck

64 Q14 Parotid tumour If the tumour is malignant it is most likely to be? a. lymphoma b. Metastatic cutaneous SCC c. Primary salivary cancer d. sarcoma Head and Neck

65 Q14 Parotid tumour If the tumour is malignant it is most likely to be? a. lymphoma b. Metastatic cutaneous SCC c. Primary salivary cancer d. sarcoma Answer: b. Metastatic cutaneous SCC Head and Neck

66 Q15 Case 7 20 yr old woman Month history of very sore throat, pain on cough and swallow radiating to ears. Very tender and hard right thyroid nodule T4 = 32, TSH= ESR =40 No toxic symptoms or signs Head and Neck

67 Q15 Most likely diagnosis a. Subacute thyroiditis b. Graves disease c. Bleed into a thyroid nodule d. Hashimotos thyroiditis Head and Neck

68 Q15 Most likely diagnosis a. Subacute thyroiditis b. Graves disease c. Bleed into a thyroid nodule d. Hashimotos thyroiditis a. Subacute or de Quervain s or painful thyroiditis Head and Neck

69 Q16 de Quervains subacute thyroiditis What is best confirming test? a. FNA b. Ultrasound c. Thyroid lobectomy d. scintigraphy Head and Neck

70 Q16 de Quervains subacute thyroiditis What is best confirming test? a. FNA b. Ultrasound c. Thyroid lobectomy d. scintigraphy d. scintigraphy- shows reduced uptake in gland Head and Neck

71 Q16 de Quervains subacute thyroiditis Inflammatory condition Thought to be viral origin (occurs in clusters) Can be ipsilateral, bilateral or sequential Ultrasound can show a suspicious, infiltrative pattern FNA Painful, shows inflammatory lymphocytes with giant cells Treatment Responds very well to anti-inflammatory steroids Follow up Repeat thyroid function tests monthly as high risk of developing hypothyroidism Head and Neck

72 Q17 Case 8 Bony hard, painless lump hard palate a. Squamous cancer b. Torus palatinus c. Burn blister d. Minor salivary gland tumour Head and Neck

73 Q17 Case 8 Bony hard, painless lump hard palate a. Squamous cancer b. Torus palatinus c. Burn blister d. Minor salivary gland tumour b. Torus palatinus: Bony exostosis of the hard palate Seen in around 20% of the population. Head and Neck

74 Q17 Torus mandibulari 7% popn More common in asians Thought to be the result of local stresses from teeth onto bone Associated with bruxism Head and Neck

75 Q18 Case 9 75 year old man Progressive dysphagia Food sticks at cricoid region Regurgitating undigested food Halitosis Gurgling noises when swallowing Head and Neck

76 Q18 Most appropriate management a. Reassure and discharge b. Antireflux therapy c. Barium swallow d. Modified diet c. barium swallow Head and Neck

77 Q18 Pharyngeal Pouch (zenkers diverticulum) Outpouching of mucosa through intrinsic weak area in pharyngeal muscle (Killians Dehiscence) Non relaxing cricopharyngeus Upper oesophageal sphincter Treatment Excise pouch Perform cricopharyngeal myotomy Head and Neck

78 Q19 Case yr old woman Sudden 3cm right thyroid swelling Ultrasound shows part fluid, part solid mass Tender to palpation Head and Neck

79 Q19 Case 10 Most likely diagnosis a. Thyroid cancer b. Viral thyroiditis c. Bleed into nodule d. Thyroid abscess Head and Neck

80 Q19 Case 10 Most likely diagnosis a. Thyroid cancer b. Viral thyroiditis c. Bleed into nodule d. Thyroid abscess c. bleed into nodule Head and Neck

81 lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis

82 thyroglossal? young patient peri-hyoid mass elevates with swallow and tongue protrusion