What Every Surgeon Should Know About Head and Neck Surgery

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What Every Surgeon Should Know About Head and
Neck Surgery

• David P Goldstein MD FRCSC
• Otolaryngology-Head Neck Surgery
• Surgical Oncology
• University Health Network
• David.goldstein_at_uhn.on.ca

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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
• thyroglossal duct and branchial cleft cyst
• Salivary gland masses
• Carotid body tumor
• Squamous cell carcinoma

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Differential Diagnosis

• Congenital
• Thyroglossal duct cyst
• Branchial cleft cyst
• Lymphangioma
• Inflammatory
• Infectious
• Non-infectious
• Neoplastic
• Primary malignancies
• Metastases to nodes

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Approach to the Differential Diagnosis of Neck
Masses

• Age
• Location, Location, Location
• Duration of symptoms
• Risk factors
• Contents of neck mass

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Differential Diagnosis

• Age is a major determinant
• lt 20 years C I N
• 20 40 years - I C N
• gt 40 years - N I C

C congenital I inflammatory N neoplastic
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Location

• Anterior Triangle
• Anterior- midline
• Posterior- SCM
• Inferior- clavicle
• Superior- mandible
• Posterior Triangle
• Anterior- post border of SCM
• Posterior- trapezius
• Superior- junction of SCM trapezius
• Inferior- clavicle

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Differential of Congenital Neck Masses Based on
Location

• Midline
• Congenital
• Thyroglossal duct cyst
• Dermoid
• Lateral Neck/Ant ?
• Congenital
• Branchial cleft cyst
• Thymic cyst
• Posterior Neck ?
• vascular/Lymphatic malformation

Beware of the cystic neck mass in an adult
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Differential Diagnosis of Neoplastic Neck Masses
based on Location

• Midline Anterior ?
• Thyroid
• Larynx cancer
• Direct extension
• Metastasis
• Posterior ?
• Benign
• Schwanomas
• Malignant
• Lymphoma
• Nodal metastasis
• Skin
• UADT
• Non H N

• Lateral Anterior ?
• Benign
• Schwanomas
• CBTs
• Salivary gland
• Malignancies
• Lymphoma
• Nodal metastasis
• UADT
• Skin
• Salivary gland

• Supraclavicular nodes (virchow nodes)
• Classically represents nodal metastases from
  below the diaphragm

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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

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Cystic Neck Mass

• Congenital
• Thyroglossal duct cyst
• Branchial cleft cyst
• Squamous cell cancer
• Oropharyngeal/ tonsil primary
• Thyroid Cancer
• WDTC present with cystic mass
• Classically has dark brown appearance
• Tail of parotid masses
• Warthins tumor

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Necrotic Neck Mass

• Infectious
• Abscess
• Tuberculosis
• Malignant
• Squamous cell carcinoma

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Work-Up of a Neck Mass

• History
• Physical
• Inspection
• Palpation
• Endoscopy
• Diagnostic Imaging
• US
• CT
• MRI
• PET
• Biopsy
• FNA
• Other
• Intraoperative endoscopy
• TB test

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History
Keep the differential diagnosis in mind

• Duration growth rate of the mass
• Malignant lesions tend to have progressive growth
  at more rapid rate than benign disease
• Location
• Anterior, posterior or midline
• Symptoms of inflammation or infection
• Malignant neck masses with necrosis and skin
  involvement may mimic invasion

• Associated symptoms
• Dysphagia, odynophagia, otalgia, hoarseness, oral
  cavity pain, nasal obstruction, epistaxis
• Suggests UADT malignancy
• B symptoms fever, weight loss night sweats
• Risk factors
• Malignancy
• TB exposure
• Cat scratch

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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

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History- Risk Factors for Malignancy

• Tobacco
• Cigarettes, chew, betel nut, cigar
• Alcohol
• Two together are synergistic
• Viruses
• HPV- oropharynx cancer
• EBV- nasopharynx cancers
• HIV- kaposis sarcoma, lymphoma
• Immunosupression
• Transplant patients- Skin cancers, head and neck
  cancer
• Occupational
• Wood working, leather work paranasal sinus
  cancer

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Risk Factors Contd

• Previous head and neck cancer
• Develop second cancer in 18 of patients
• Radiation exposure
• Salivary gland cancers, thyroid cancer, head and
  neck sarcomas
• Autoimmune disorders
• Sjogrens syndrome
• lymphoma of salivary glands
• Hashimotos thyroiditis
• thyroid lymphoma

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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

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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

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Fine Needle Aspiration

• Diagnostic accuracy 70 to 90
• Simple/ cost effective
• US guidance increases yield accuracy
• Indication almost any neck mass
• Only relative contraindication to FNA is
  pulsatile neck mass

MOST IMPORTANT TEST- WHEN IN DOUBT PERFORM
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Fine Needle Aspiration

• Diagnose most head and neck cancers
• Suspect lymphoma
• Send for flow cytometry
• Cystic neck mass
• 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

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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

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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

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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

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Diagnostic Imaging

• Plain films
• Limited role
• CXR
• Ultrasound/Doppler
• Useful noninvasive test
• Vascularity
• Solid vs Cystic
• Sensitive for adenopathy
• Guided FNA

• CT scan MRI
• Location
• Relation to other structures
• Vascularity
• Bone invasion
• MRI for soft tissue
• Tongue
• No dental artifact
• MRA/MRV

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• MRI
• Soft tissue
• No dental artifact oral oropharynx
• Bone invasion

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• CT scans
• Bone imaging
• Soft tissue imaging
• Dental artifact

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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

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Presentation Management of Specific Diagnosis
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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

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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

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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

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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

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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 lyres sign
• MRI get salt pepper pattern from the flow voids
  

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Carotid Body Tumor

• Treatment
• Excision
• Proximal and distal control of CA
• Prepared to bypass
• Complications
• Vascular injury
• Stroke
• CN injury CN IX,X,XII

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Squamous Cell Carcinoma
FNA Dx of SCC
Primary detected
No Primary identified Aka unknown primary
Stage tumor
Imaging to stage the neck disease and help
identify the primary source
Primary Identified
Treat primary tumor Treat neck
Panendoscopy in OR with biopsies of tongue base,
hypopharynx, nasopharynx and unilateral
tonsillectomy
Treat neck and potential primary sites with
radiation
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Squamous cell carcinomaGeneral Management
Principles

• Staging
• Hx, Px (flex scope)
• Imaging
• 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

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Squamous cell carcinomaGeneral Management
Principles

• Treatment Options
• 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

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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
• Organ preservation (larynx, hypopharynx)
• Preserve form and function (oropharynx
• Swallowing, speech, cosmesis

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Goals of Treatment

• Cure
• Local regional control
• Survival
• Palliation
• Pain
• Bleeding
• Cosmesis

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Squamous cell carcinomaGeneral Management
Principles

• 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

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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

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Salivary Gland Masses

• Major Salivary Glands
• Parotid- 80
• (80benign20malignant)
• Submandibular 15 (5050)
• Sublingual (4060)
• Minor Salivary Glands
• Oral cavity/ oropharynx
• Larynx
• Nose paranasal sinuses

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Classification
Hemangiomas Vascular malformations Lymphatic
malformations 1st Branchial cleft cyst
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Classification
HIV TB Atypical TB Actinomycosis Cat-Scratch
Toxoplasmosis Tularemia Fungal
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History Physical Exam

• Majority of neoplasms (benign or malignant)
  present as asymptomatic swelling
• Risk factors for malignancy
• Majority idiopathic
• Ionizing radiation
• Sjogrens syndrome
• Lymphoma
• Skin cancers

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Clinical Presentation of Cancers

• Pain
• Fixation invasion of surrounding structures
  i.e. dermis, mandible
• Trismus
• Facial nerve paralysis
• Adenopathy

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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

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Lab Tests

• Serology if suspect auto-immune process

Biopsy

• FNA mainstay
• Open biopsy
• Very rarely indicated for parotid masses AVOID
  in most cases

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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

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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

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Diagnostic Imaging

• Ultrasound
• Identifying a mass
• Guide FNA
• Assessing adenopathy
• Technitium-99m Scan
• Diagnosis of Oncocytoma or Warthins 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

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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

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Common Pathologies

• Benign
• Pleomorphic adenoma
• Malignant degeneration into carcinoma
  ex-pleomorphic adenoma in 2-10 of pleomorphic
  adenomas
• Warthins tumor
• 10 bilateral
• Malignant
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Metastases from skin cancers

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Prognostic Factors with Malignancy

• Histology
• High Grade Malignancies
• Older Age
• Pain at presentation
• Stage of primary tumor nodal metastases
• Skin invasion
• Facial nerve dysfunction
• Peri-neural growth
• Positive margins

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Malignant Secondary Neoplasms

• Direct extension
• Cutaneous SCC/BCC
• Lymphatic metastases
• SCC
• Melanoma
• Hematogenous
• Metastases
• Lung, Kidney, Breast

Direct extension
Metastatic SCC
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Factors in Decision Making

• Patient factors
• Age
• Co-morbidities
• Patients concerns
• Tumor Factors
• Histology
• Benign vs malignant
• Do you have a diagnosis how certain are we
• Growth rate
• Risk factors for malignancy

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Surgery

• Majority can be managed with a superficial
  parotidectomy
• Subtotal parotidectomy
• Involvement of deep lobe
• Parotidectomy and transcervical approach to
  parapharyngeal space tumours

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Surgical Complications

• Temporary VII nerve paresis21
• Freys syndrome6
• Infection3.6
• Hematoma2.7
• Hypertrophic scar2.4
• Seroma0.8
• Salivary fistula0.4

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Indications for Post-operative Radiotherapy

• High grade cancers
• Recurrent cancers
• Gross or microscopic residual disease
• Regional lymph node metastases
• Evidence of locally advanced tumors

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Thyroid Cancer
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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 20062952164-2167.
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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

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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

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Medullary Thyroid Carcinoma

• C - cell/parafollicular cell origin
• May be sporadic/nonfamilial (80) or familial
  (20)
• Familial forms
• Medullary thyroid carcinoma alone
• MEN 2A (Sipples)
• MTC, Pheochromcytoma, Hyperparathyroidism
• MEN 2B
• MTC, Pheochromocytoma, Mucosal Neuromas,
• Mutations on chromosome 10 for the RET
  proto-oncogene
• Regional lymph node metastases - 50
• Distant metastases

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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

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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

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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

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Lymphoma of Thyroid Gland
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Thyroid Nodules

• Approximately 95 of thyroid nodules are benign
• 4-7 of adults have thyroid nodules
• Women gt men
• Likelihood of malignancy5
• Malignancy in clinically apparent nodules20

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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

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Investigations

• FNA
• Thyroid U/S
• TSH
• No role for calcitonin, thyroglobulin and thyroid
  scintigraphy in the initial work-up

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FNA
FNA (R-A)
Repeatedly Nondiagnostic (R-A)
Indeterminate Cytology (suspicious, follicular
lesion or neoplasm)
Benign
Follicular lesion
Suspicious for papillary ca or
Hurthle cell neoplasm
Cystic nodule
Solid nodule
Thyroid scan
Hot
Cold (R-B)


Surgery strongly considered
Surgery (R- A)
Observation or surgery
Follow (R-A)
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Risk-group Definitions

• AGES
• A age (gt 40)
• G grade
• E extent of tumor
• extrathyroidal invasion
• distant metastases
• S size
• Other TNM MACIS

• AMES
• A age(Mgt40,Fgt50)
• M metastases (distant)
• E extent of tumor
• S size

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Treatment

• Surgery
• Post-operative radioactive iodine
• Post-operative thyroid suppression
• External beam radiation
• Post-operative screening

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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

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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

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Complications of Thyroidetcomy

• Hypoparathyroidism
• Temp vs Permanent
• Recurrent Laryngeal Nerve Injury
• Unilat vs bilat
• Temp vs Perm

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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

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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

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Radioactive Iodine

• Agent - I131
• Effect
• Goal of therapy
• Scan
• Thyroid ablation
• Therapeutic
• Complications
• Short term
• Long term

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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

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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
• surgery can be performed at that time point
• Remains stable or diagnosed in 2nd half of
  pregnancy
• surgery may be performed after delivery
• Low TSH
• if persists after 1st trimester
• thyroid scan after pregnancy