Head and Neck Case Studies John Chaplin & Nick McIvor www.headneck.co.nz Head and Neck
lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis
lumps factors to consider age & duration tissue & site number auckland head & neck associates
lumps factors to consider age & duration 25 20 15 10 5 Congenital Inflammatory Benign neop Malign neop 0 <20 20-40 >40 auckland head & neck associates
lumps factors to consider age & duration tissue & site auckland head & neck associates
lumps factors to consider age & duration tissue & site number auckland head & neck associates
FNA pulsatile mass non diagnostic aspirate sites US guided FNA
pulsatile mass & bleeding usually FNA not necessary or advisable (bruising only) diagnosis aneurysmal artery tortuous artery Cf elderly carotid body tumour
non-diagnostic aspirate solid vs cystic
evolution of metastasis
evolution of metastasis
evolution of metastasis subcortical
evolution of metastasis subcortical
evolution of metastasis hilar effacement
evolution of metastasis nodal rounding?palpable
evolution of metastasis extranodal extension
thyroid nodules Bethesda system % malig 1. Non diagnostic 5 2. Benign 3 3. Follicular undetermined 15 4. Follicular neoplasm 20 5. Suspicious malig 50 6. Malignant 100
non-diagnostic and benign Reason Cystic Complex Bloody Multiple Plan Repeat USGFNA
USFNA
ultrasound in FNA thyroid nodule posterior nodule partially cystic multiple suspicious features microcalcification internal vascularity hypoechoic irregular halo taller than wide on transverse view
parotid gland adenoma metastatic node adenocarcinoma
parotid gland Mixed cellular population with myxoid stroma pleomorphic adenoma
parotid gland Mixed cellular population with myxoid stroma pleomorphic adenoma 95% accuracy Continue to grow Potential malignant change
submandibular whole gland Fluctuating stable lump within gland adenoma adencarcinoma lump outside gland node reactive lymphoma metastatic
lymphoid aspirate suggests reactive lymphadenopathy monoclonal population can not be excluded.. assess in clinical context.
lymphoid aspirate suggests reactive lymphadenopathy monoclonal population can not be excluded.. assess in clinical context.
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
USFNA - equipment Needle- 22 gauge Syringe - 5ml Glass slides Pencil Pottle Saline Band-aid Ultrasound (optional)
technique Multiple passes
USFNA neck mass partially necrotic suspicious features aspirate for assay Thyroglobulin Calcitonin Parathyroid Hormone
lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis
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
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
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
Q2 Most approp test a. Oral cavity exam b. Flexible endoscopy c. FNA d. skin examination e. All of the above Head and Neck
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
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
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
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
Q5 Most common neck node involved in oropharyngeal cancer? 1. submandibular 2. Parotid 3. upper lateral neck 4. Lower lateral neck 5. Posterior triangle
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
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
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
Q7 Most common cause of tonsil/base of tongue cancer? 1. Smoking 2. alcohol 3. Smoking and alcohol 4. EBV 5. Oral sex
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
Q8 Overall cure rate for tonsil/base of tongue cancer? 1. 0% 2. 25% 3. 50% 4. 75% 5. 100%
Q8 Overall cure rate for tonsil/base of tongue cancer? 1. 0% 2. 25% 3. 50% 4. 75% 5. 100% Answer: 4. 75%
Q9 What is the NZ HPV vaccination schedule? 1. There is none 2. Vaccinate girls 11-12 3. Vaccinate girls and boys 11-12 4. Vaccinate females 11-26 5. Vaccinate both sexes 11-26
Q9 What is the NZ HPV vaccination schedule? 1. There is none 2. Vaccinate girls 11-12 3. Vaccinate girls and boys 11-12 4. Vaccinate females 11-26 5. Vaccinate both sexes 11-26 Answer: 2. vaccinate girls 11-12
Q10 Case 2 40 year old male 1 month submental/submandib lumps healthy oral cavity and skin
Q10 Case 2 most likely diagnosis? 1. acne 2. tonsillitis 3. Glandular fever 4. toxoplasmosis 5. lymphoma
Q10 Case 3 most likely diagnosis? 1. acne 2. tonsillitis 3. Glandular fever 4. toxoplasmosis 5. lymphoma Answer: toxoplasmosis but you must prove it
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
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
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
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
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
Q12 Case 4 29 yr old man 6 months lump angle of jaw No pain, tenderness Head and Neck
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
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
Q13 Patient presents with parotid mass and this facial examination. What is most likely tumour. a. Adenoma b. Carcinoma c. Schwannoma Head and Neck
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
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
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
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= 0.002 ESR =40 No toxic symptoms or signs Head and Neck
Q15 Most likely diagnosis a. Subacute thyroiditis b. Graves disease c. Bleed into a thyroid nodule d. Hashimotos thyroiditis Head and Neck
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
Q16 de Quervains subacute thyroiditis What is best confirming test? a. FNA b. Ultrasound c. Thyroid lobectomy d. scintigraphy Head and Neck
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
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
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
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
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
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
Q18 Most appropriate management a. Reassure and discharge b. Antireflux therapy c. Barium swallow d. Modified diet c. barium swallow Head and Neck
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
Q19 Case 10 35 yr old woman Sudden 3cm right thyroid swelling Ultrasound shows part fluid, part solid mass Tender to palpation Head and Neck
Q19 Case 10 Most likely diagnosis a. Thyroid cancer b. Viral thyroiditis c. Bleed into nodule d. Thyroid abscess Head and Neck
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
lumps every lump must have a diagnosis Working diagnosis» +/- investigations Review» +/- investigations auckland head & neck associates Resolution Definitive diagnosis
thyroglossal? young patient peri-hyoid mass elevates with swallow and tongue protrusion