Transcript What Every Surgeon Should Know About Head and Neck Surgery David P Goldstein MD FRCSC Otolaryngology-Head & Neck Surgery Surgical Oncology University Health Network [email protected].

What Every Surgeon Should Know
About Head and Neck Surgery
David P Goldstein MD FRCSC
Otolaryngology-Head & Neck Surgery
Surgical Oncology
University Health Network
[email protected]
Objectives

Focus on approach to evaluation and management
of a neck mass and Parotid masses

Briefly highlight key issues in diagnosis &
management of following types of neck mass

Congenital disorders
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


thyroglossal duct and branchial cleft cyst
Salivary gland masses
Carotid body tumor
Squamous cell carcinoma
Differential Diagnosis

Congenital




Inflammatory



Thyroglossal duct cyst
Branchial cleft cyst
Lymphangioma
Infectious
Non-infectious
Neoplastic


Primary malignancies
Metastases to nodes
Approach to the Differential
Diagnosis of Neck Masses
Age
 Location, Location, Location
 Duration of symptoms
 Risk factors
 Contents of neck mass

Differential Diagnosis




Age is a major determinant
< 20 years –
C
I
N
20 – 40 years - I
C
N
> 40 years N
I
C
C= congenital
I= inflammatory
N= neoplastic
Location

Anterior Triangle





Anterior- midline
Posterior- SCM
Inferior- clavicle
Superior- mandible
Posterior Triangle

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
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Anterior- post border of
SCM
Posterior- trapezius
Superior- junction of SCM
& trapezius
Inferior- clavicle
Differential of Congenital Neck Masses
Based on Location

Midline

Congenital



Lateral Neck/Ant Δ

Congenital



Thyroglossal duct cyst
Dermoid
Branchial cleft cyst
Thymic cyst
Posterior Neck Δ

vascular/Lymphatic
malformation
Beware of the cystic neck mass
in an adult
Differential Diagnosis of Neoplastic Neck
Masses based on Location

Lateral Anterior Δ
 Benign
 Schwanomas
 CBTs
 Salivary gland

Malignancies
 Lymphoma
 Nodal metastasis
 UADT
 Skin
 Salivary gland

Midline Anterior Δ


Thyroid
Larynx cancer
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

Direct extension
Metastasis
Posterior Δ

Benign


Schwanomas
Malignant


Lymphoma
Nodal metastasis



Skin
UADT
Non H & N
Supraclavicular nodes (virchow nodes)
- Classically represents nodal metastases from below the diaphragm
Differential Based on Growth Rate

Slow growing over years


Tend to be benign or low grade malignancy
Rapidly growing neck masses


Infectious
Malignant – tend to progress over period of
weeks to a few months
Cystic Neck Mass

Congenital



Squamous cell cancer


Oropharyngeal/ tonsil primary
Thyroid Cancer



Thyroglossal duct cyst
Branchial cleft cyst
WDTC present with cystic mass
Classically has dark brown appearance
Tail of parotid masses

Warthin’s tumor
Necrotic Neck Mass

Infectious



Abscess
Tuberculosis
Malignant

Squamous cell carcinoma
Work-Up of a Neck Mass


History
Physical




Diagnostic Imaging




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US
CT
MRI
PET
Biopsy


Inspection
Palpation
Endoscopy
FNA
Other


Intraoperative endoscopy
TB test
History
Keep the differential diagnosis in mind

Duration & growth rate of the
mass


Associated symptoms

Malignant lesions tend to have
progressive growth at more
rapid rate than benign disease
Dysphagia, odynophagia,
otalgia, hoarseness, oral
cavity pain, nasal obstruction,
epistaxis


Location



Anterior, posterior or midline
Symptoms of inflammation or
infection
 Malignant neck masses with
necrosis and skin
involvement may mimic
invasion

Suggests UADT malignancy
B symptoms – fever, weight
loss & night sweats
Risk factors



Malignancy
TB exposure
Cat scratch
History

Past medical history






Skin cancer
UADT malignancy
Sarcoidosis
Fungal infection
Dental caries/dental
work
Trauma to head and
neck

Family history


Thyroid cancer
Paragangliomas
History- Risk Factors for Malignancy


Tobacco
 Cigarettes, chew, betel nut, cigar
Alcohol


Viruses





Two together are synergistic
HPV- oropharynx cancer
EBV- nasopharynx cancers
HIV- kaposi’s sarcoma, lymphoma
Immunosupression
 Transplant patients- Skin cancers, head and neck cancer
Occupational
 Wood working, leather work – paranasal sinus cancer
Risk Factors Cont’d

Previous head and neck cancer


Radiation exposure


Develop second cancer in 18% of patients
Salivary gland cancers, thyroid cancer, head and neck sarcomas
Autoimmune disorders

Sjogren’s syndrome


lymphoma of salivary glands
Hashimoto’s thyroiditis

thyroid lymphoma
Physical Examination

Neck mass








Location
Size
Firmness
Fixation
Pulsatile
Presence of other neck masses or enlarged nodes
Movement with tongue protrusion
Auscultate for bruits if pulsatile
Investigations




If diagnosis of infectious or inflammatory is probable no
further work up is necessary and appropriate therapy
instituted
Suspected inflammatory disorders may require serologic
tests
If there is any uncertainty in diagnosis or the suspected
diagnosis is congenital or neoplastic further
investigations are required
When in doubt on your exam – do further investigations
Fine Needle Aspiration
• Diagnostic accuracy 70% to 90%
• Simple/ cost effective
MOST
IMPORTANT
WHEN IN
• US guidance
increases TESTyield & accuracy
DOUBT
PERFORM
• Indication – almost any neck mass
• Only relative contraindication to FNA is pulsatile neck mass
Fine Needle Aspiration

Diagnose most head and neck cancers

Suspect lymphoma


Cystic neck mass



Send for flow cytometry
Send washings
Stain for thyroglobulin
Still a role for FNA in infectious and inflammatory
disorders


C&S
Presence of pus does not necessarily exclude malignancy

Squamous cell carcinoma can present with necrotic nodes
Open Biopsy

Almost NO role in the initial work-up of a neck mass

Contraindications




Pulsatile masses
Parotid masses
Suspected malignancies and FNA not been attempted
When to do

Only after work-up is completed including FNA and diagnosis is
still in question


FNA is non-diagnostic
FNA is negative but not in keeping with clinical picture
Open Biopsy

Situations in which may be indicated

Lymphoma


FNA is suspicious for lymphoma & further tissue
needed
Cystic neck mass
FNA often inconclusive
 Send cyst fluid for cytology
 Do full work-up prior to open biopsy


Imaging and panendoscopy of UADT
Open Biopsy

Incisional vs excisional biopsy


Depends upon size, location and involvement if
surrounding structures and suspected pathology
Keep in mind future surgery/neck dissection

Make the incision in line with potential incision one
would use if further neck surgery is required
Diagnostic Imaging

Plain films

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Limited role
CXR
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CT scan & MRI
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Ultrasound/Doppler





Useful noninvasive test
Vascularity
Solid vs Cystic
Sensitive for adenopathy
Guided FNA


Location
Relation to other structures
Vascularity
Bone invasion
MRI for soft tissue



Tongue
No dental artifact
MRA/MRV

MRI



Soft tissue
No dental artifact –
oral & oropharynx
Bone invasion

CT scans



Bone imaging
Soft tissue imaging
Dental artifact
The Pulsating Neck Mass

Differential Diagnosis




Non-vascular mass situated near carotid artery
Carotid body tumor (paraganglioma)
Carotid artery aneurysm
Work-up

Image first




CT with contrast or MRI
If confirmed vascular mass get MRI (MRA & MRV)
Avoid FNA but not end of world
Incisional biopsy contraindicated
Presentation & Management
of Specific Diagnosis
Thyroglossal Duct Cyst

Presentation





May occur at any age but
most common in first 2
decades of life
Midline at level of hyoid to
thyroid, may be off centre
May have hx of infection
Classic sign is rising with
tongue extrusion
Diagnosis


History & Physical
Imaging
Thyroglossal Duct Cyst

Cautions



May have papillary ca arising in thyroglossal duct cyst
– rare but I perform FNA
Cystic nodal metastasis from papillary thyroid ca to
delphian node may have similar presentation
Treatment


Excision – sistrunk procedure (remove cyst with track
up to tongue base including central portion of hyoid
bone)
Cosmetic and prevent recurrent infection
Branchial Cleft Cyst

Presentation



mass along the anterior border
of the SCM +/- a sinus tract
Smooth painless slow growing
unless infected, may fluctuate
in size
Treatment


Surgical excision with removal
of the tract
Nerves at risk – CN IX, X, XI
XII
Lymphoma
• hx of lymphadenopathy – non-resolving
• B symptoms – fever, night sweats, weight loss
• nodes soft mobile and rubbery, may be very large “bull neck”
Diagnosis
• FNA- special solution & adequate amount
• Open biopsy- after FNA & lymphoma suspicious clinically
• must be sent fresh
• immunophenotyping & flow cytometry
Carotid Body Tumor


Carotid body tumors
(Paraganglioma)
 Arise from carotid body located at
bifurcation between ICA & ECA
 Familial in up to 30%
 Bilateral or multiple
Diagnosis
 Classic imaging characteristics
 Vascular mass splaying ICA
and ECA – lyre’s sign
 MRI get salt & pepper pattern
from the flow voids
Carotid Body Tumor


Treatment
 Excision
 Proximal and distal control of CA
 Prepared to bypass
Complications
 Vascular injury
 Stroke
 CN injury – CN IX,X,XII
Squamous Cell Carcinoma
FNA Dx of SCC
Primary detected
Stage tumor
Treat primary tumor
Treat neck
No Primary identified; Aka unknown primary
Imaging to stage the neck disease and help
identify the primary source
Panendoscopy in OR with biopsies of tongue
base, hypopharynx, nasopharynx and
unilateral tonsillectomy
Treat neck and potential primary
sites with radiation
Squamous cell carcinoma
General Management Principles

Staging

Hx, Px (flex scope)

Imaging
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CT Head and neck
MR for tongue/tongue base
Chest CT r/o synchronous primary
Panedoscopy/Quadroscopy (EUA under GA)


Esophagoscopy, Bronchoscopy, Laryngoscopy, +/- nasopharynx
Used for cancers of larynx, hypopharynx and +/- oropharynx



Assess the extent of the tumor & surgical resectabilty
Obtain biopsy specimens
Assess for 2nd primary
Squamous cell carcinoma
General Management Principles
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Treatment Options
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Surgery
Radiation
Chemotherapy
Combination of both


Rads or chemo can be given pre- or post op
Treat the primary site and the cervical lymph
nodes

Try and treat cervical lymph nodes with the same
modality of therapy used for the primary site
How do we decide which treatment
to offer

Provide the treatment that will offer the highest
survival & control rate




based on literature
Early stage disease often similar
Advanced disease usually combination
QOL and morbidity


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Organ preservation (larynx, hypopharynx)
Preserve form and function (oropharynx
Swallowing, speech, cosmesis
Goals of Treatment

Cure


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Local regional control
Survival
Palliation



Pain
Bleeding
Cosmesis
Squamous cell carcinoma
General Management Principles


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Oral cavity – surgery
Oropharynx (tonsil, tongue base)- radiation or
chemoradiation
Hypopharynx cancer – radiation or
chemoradiation
Larynx- transoral laser surgery for small tumors,
radiation or chemoradiation for most
Nasopharynx- chemoradiation or radiation
Adenocarcinoma

FNA diagnosis of adenocarcinoma in the neck –
from a distant site




Lung, breast, GI, GU
May require an open biopsy to get more tissue
for analysis to help identify site
Image chest, abdo, pelvis
Rarely treat the neck b/c metastatic disease palliative therapy to prevent obstruction of
trachea or esophagus

Neck dissection - Only if primary site is controlled and
patient is potentially curable
Salivary Gland Masses

Major Salivary Glands

Parotid- 80%




(80%benign:20%malignant)
Submandibular 15% (50:50)
Sublingual (40:60)
Minor Salivary Glands



Oral cavity/ oropharynx
Larynx
Nose & paranasal sinuses
Classification
Non-Neoplastic
Hemangiomas
Congenital
Vascular
malformations
Granulomatous
Lymphatic
malformations
Infectious
Non-infectious
Inflammatory
1st Branchial
cleft cyst
Classification
Non-Neoplastic
Congenital
Granulomatous
Infectious
Non-infectious
Inflammatory
HIV
TB
Atypical TB
Actinomycosis
Cat-Scratch
Toxoplasmosis
Tularemia
Fungal
History & Physical Exam


Majority of neoplasms (benign or malignant)
present as asymptomatic swelling
Risk factors for malignancy

Majority idiopathic
Ionizing radiation
Sjogren’s syndrome
Lymphoma

Skin cancers



Clinical Presentation of Cancers





Pain
Fixation & invasion of surrounding
structures i.e. dermis, mandible
Trismus
Facial nerve paralysis
Adenopathy
Facial Nerve Paralysis with a
Parotid Mass



Very rarely occurs with benign tumors
12% to 15% parotid malignancies will
exhibit facial paralysis
Pathologies



Adenoid cystic carcinoma
Poorly differentiated carcinoma
SCC
Lab Tests

Serology if suspect auto-immune
process
Biopsy


FNA – mainstay
Open biopsy

Very rarely indicated for parotid masses: AVOID in
most cases
Fine Needle Aspiration



Debate about utility of FNA in parotid masses
Among all H & N sites the parotid gland is associated
with the highest FNA inaccuracy rates
False negative rates higher then false positive

Sensitivity rates reported can be as low as 38% when comes
to recognizing malignant nature of parotid masses

Diagnostic precision is difficult

Determine high vs. low grade tumors is also difficult
Why do an FNA?

Accuracy in determining benign from malignant
disease

Rates of ~ 90%

It may help in planning surgery especially informed
consent

It may help in timing of surgery in resource
restricted climate

Change clinical approach in up to 30% of patients

Results interpreted in the face of the clinical
presentation and imaging
Diagnostic Imaging




Ultrasound
 Identifying a mass
 Guide FNA
 Assessing adenopathy
Technitium-99m Scan
 Diagnosis of Oncocytoma or
Warthin’s tumor
Sialography
 Rarely used
 Little role in routine work-up of
a parotid mass
CT Scan and/or MRI
 Main modalities for
imaging parotid
neoplasms
Value of Imaging

Know what you are getting into



“tip of iceberg” with deep lobe involvement
Approach
Malignancy

Resectability




Skull base
Structures requiring resection
Nodal status
Facial nerve status

Adenoid cystic carcinoma- proximal portion
Common Pathologies

Benign

Pleomorphic adenoma


Warthin’s tumor


Malignant degeneration into carcinoma ex-pleomorphic
adenoma in 2-10% of pleomorphic adenomas
10% bilateral
Malignant



Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Metastases from skin cancers
Prognostic Factors with Malignancy

Histology


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
High Grade Malignancies
Older Age
Pain at presentation
Stage of primary tumor & nodal metastases
Skin invasion
Facial nerve dysfunction
Peri-neural growth
Positive margins
Malignant Secondary
Neoplasms
Direct extension
Cutaneous SCC/BCC
Direct extension
Lymphatic metastases
SCC
Melanoma
Hematogenous
Metastases
Lung, Kidney, Breast
Metastatic SCC
Factors in Decision Making

Patient factors

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

Age
Co-morbidities
Patient’s concerns
Tumor Factors

Histology




Benign vs malignant
Do you have a diagnosis & how certain are we
Growth rate
Risk factors for malignancy
Surgery


Majority can be managed with a superficial
parotidectomy
Subtotal parotidectomy


Involvement of deep lobe
Parotidectomy and transcervical approach to
parapharyngeal space tumours
Surgical Complications







Temporary VII nerve paresis=21%
Frey’s syndrome=6%
Infection=3.6%
Hematoma=2.7%
Hypertrophic scar=2.4%
Seroma=0.8%
Salivary fistula=0.4%
Indications for Post-operative
Radiotherapy





High grade cancers
Recurrent cancers
Gross or microscopic residual disease
Regional lymph node metastases
Evidence of locally advanced tumors
Thyroid Cancer
Epidemic of Thyroid Cancer

3.6 per 100 000 in 1973 → 8.7 per 100 000 in 2002
 represents 2.4 fold increase
Davies, L. et al. JAMA 2006;295:2164-2167.
Thyroid Malignancies

Well-Differentiated Carcinomas (80-85%)
Papillary Thyroid Carcinoma (PTC)
 Follicular Thyroid Carcinoma (FTC)




Medullary Thyroid Carcinoma (5-10%)
Anaplastic Thyroid Carcinoma (5-10%)
Other malignancies
Lymphomas
 Distant Metastases

Well-Differentiated
Thyroid Carcinoma

Papillary Thyroid CA






75-80% of thyroid
carcinomas
Frequently Multifocal
Dx on FNA or FS
Common Nodal Dz
Infrequent Distant Dz
Slightly Better Prognosis

Follicular Thyroid CA







5-10% of all thyroid
carcinomas
more aggressive natural
history
Solitary Lesion
Dx on final path
Infrequent Nodal Dz
Common Distant Dz
Slightly Worse Prognosis
Medullary Thyroid Carcinoma



C - cell/parafollicular cell origin
May be sporadic/nonfamilial (80%) or familial (20%)
Familial forms

•
Medullary thyroid carcinoma alone
MEN 2A (Sipple’s)

•
MEN 2B




MTC, Pheochromcytoma, Hyperparathyroidism
MTC, Pheochromocytoma, Mucosal Neuromas,
Mutations on chromosome 10 for the RET protooncogene
Regional lymph node metastases - 50%
Distant metastases
Medullary Thyroid
Carcinoma

Diagnosis / Screening
Pentagastrin Stimulation with measurement of
calcitonin levels
• Ret proto-oncogene screening
Patients who screen positive should undergo early
thyroidectomy
Early intervention has resulted in 85% DFS at 15-20
years
Serum calcitonin levels are used as a tumor marker
in follow-up
•



Medullary Thyroid
Carcinoma

Treatment
•
•
•
•
•

exclude pheochromocytoma
total thyroidectomy
central compartment lymphadenectomy
elective lateral neck dissection for patients with
palpable thyroid disease
therapeutic lateral neck dissection for patients
with palpable neck disease
Treatment
•
•
Adjuvant external beam radiation may be used to
enhance locoregional control
The role of chemotherapy remains to be defined
Anaplastic Carcinoma



Rare tumor noted for its rapid growth and
nearly uniform lethal nature
Typically develops in a pre-existing well
differentiated thyroid carcinoma or a
goiter
Poor prognostic factors


Advanced age
Presence of regional or distant metastases
Lymphoma of Thyroid Gland
Thyroid Nodules





Approximately 95% of thyroid nodules are
benign
4-7% of adults have thyroid nodules
Women > men
Likelihood of malignancy=5%
Malignancy in clinically apparent
nodules=20%
Work-up of Thyroid Nodule

History



exposure to ionizing radiation
family history of thyroid carcinoma or other endocrine
neoplasms (MEN syndromes)
Physical examination



Vocal cord paralysis
Fixed and firm
Cervical nodes
Investigations




FNA
Thyroid U/S
TSH
No role for calcitonin, thyroglobulin and
thyroid scintigraphy in the initial work-up
FNA
FNA (R-A)
Repeatedly
Nondiagnostic (R-A)
Cystic
nodule
Solid
nodule
Indeterminate Cytology
(suspicious, follicular
lesion or neoplasm)
Benign
Follicular
lesion
“Suspicious” for
papillary ca or
Hurthle cell
neoplasm
Thyroid
scan
Cold
(R-B)
Observation
or surgery
Surgery
strongly
considered
Surgery
(R- A)
Hot
Follow
(R-A)
Risk-group Definitions
AGES
 A – age (> 40)
 G – grade
 E – extent of tumor


extrathyroidal invasion
distant metastases

S – size

Other TNM & MACIS
AMES
 A – age(M>40,F>50)
 M – metastases
(distant)
 E – extent of tumor
 S – size
Patterns of Failure by Risk Groups
Differentiated Thyroid Cancer
% of pts
40
35
30
25
Local %
Regional %
Distant %
Overall %
50%
26%
20
34
13%
15
10
5
0
5
14 12
10
10
18 17
2
Low
Intermediate
High
Treatment
 Surgery




Post-operative radioactive iodine
Post-operative thyroid suppression
External beam radiation
Post-operative screening
Total vs Less than Total
Thyroidectomy




Eliminates all cancer and
potential cancer (up to
50% CL)
Allows RAI
Allows monitoring with
thyroglobulin
Deals with tall cell and
insular Ca & prevents
transformation of PTC to
anaplastic ca




No compelling
evidence for survival
advantage
Difficult for RAI
Thyroglobulin not
possible
Spares the
parathyroids & RLN
Hemi vs Total Thyroidectomy

Low risk disease




Controversial
R.R decreased with total thyroidectomy
Some studies shown no difference
High risk patients


Local & regional RR lower in total thyroidectomy
Possibly improved cause specific survival
Complications of Thyroidetcomy

Hypoparathyroidism


Temp vs Permanent
Recurrent Laryngeal Nerve Injury


Unilat vs bilat
Temp vs Perm
Complications

Post-operative hematoma




Concern re: airway
Prevent obstruction with incomplete strap
muscle reapprox inferiorly
Drains do not prevent
Management
Airway emergency
 Open at bedside if patient in resp distress
 To OR

Neck Management


Clinically negative neck no neck dissection
Nodal metastases at presentation




Do not adversely affect survival
Does increase risk of locoregional recurrence
80% of nodal metastases are central compartment
Lateral ND only if clinically positive nodes or identified
intra-op


Functional neck dissection level II-V
Spare IJV, SCM, CN XI, cervical plexus
Radioactive Iodine



Agent - I131
Effect
Goal of therapy




Scan
Thyroid ablation
Therapeutic
Complications


Short term
Long term
Radioactive Iodine


Only useful in cases of well differentiated
thyroid malignancies
Results




Overall efficacy difficult to clearly delineate
Studies have shown decreased locoregional
recurrences and increased survival in some series
Less efficacious in unresectable disease
Pulmonary metastases respond better than bony
metastases
Thyroid Nodules in Pregnancy

Uncertainty if nodules in pregnancy are more likely to be malignant
than those found in non-pregnant women


No population based studies
Recommendations (C)
 FNA unless low TSH
 Malignancy- follow with U/S
 Significant growth by 24 wks gestation


Remains stable or diagnosed in 2nd half of pregnancy


surgery can be performed at that time point
surgery may be performed after delivery
Low TSH

if persists after 1st trimester

thyroid scan after pregnancy