What Every Surgeon Should Know About Head and Neck SurgeryDavid P Goldstein MD FRCSCOtolaryngology-Head & Neck SurgerySurgical OncologyUniversity Health Network David.goldstein@uhn.on.ca

ObjectivesFocus 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 massCongenital disordersthyroglossal duct and branchial cleft cyst Salivary gland masses Carotid body tumor Squamous cell carcinoma

Differential Diagnosis Congenital Thyroglossal duct cyst Branchial cleft cystLymphangioma

Inflammatory Infectious Non-infectious

NeoplasticPrimary malignanciesMetastases to nodes

Approach to the Differential Diagnosis of Neck Masses Age Location, Location, LocationDuration of symptoms Risk factorsContents of neck mass

Differential DiagnosisAge is a major determinant < 20 years C I N 20 40 years - ICN> 40 years -NICC= congenitalI= inflammatory N= neoplastic

LocationAnterior Triangle Anterior- midlinePosterior- SCMInferior- clavicle Superior- mandible

Posterior Triangle Anterior- post border of SCMPosterior- trapezius Superior- junction of SCM & trapeziusInferior- clavicle

Midline CongenitalThyroglossal duct cyst Dermoid

Lateral Neck/Ant CongenitalBranchial cleft cystThymic cyst

Posterior Neck vascular/Lymphatic malformation

Beware of the cystic neck mass in an adult Differential of Congenital Neck Masses Based on Location

Differential Diagnosis of Neoplastic Neck Masses based on Location Lateral Anterior BenignSchwanomasCBTsSalivary gland

MalignanciesLymphomaNodal metastasisUADTSkinSalivary gland

Midline Anterior Thyroid Larynx cancerDirect extension Metastasis

Posterior Benign SchwanomasMalignant LymphomaNodal metastasisSkinUADTNon H & N Supraclavicular nodes (virchow nodes) Classically represents nodal metastases from below the diaphragm

Differential Based on Growth Rate Slow growing over yearsTend to be benign or low grade malignancy

Rapidly growing neck massesInfectiousMalignant tend to progress over period of weeks to a few months

Cystic Neck MassCongenital Thyroglossal duct cyst Branchial cleft cyst

Squamous cell cancerOropharyngeal/ tonsil primary

Thyroid CancerWDTC present with cystic mass Classically has dark brown appearance

Tail of parotid masses Warthins tumor

Necrotic Neck MassInfectious Abscess Tuberculosis

Malignant Squamous cell carcinoma

Work-Up of a Neck MassHistory Physical Inspection Palpation EndoscopyDiagnostic ImagingUS CT MRIPETBiopsy FNAOther Intraoperative endoscopyTB test

HistoryDuration & growth rate of the massMalignant lesions tend to have progressive growth at more rapid rate than benign disease

Location Anterior, posterior or midline

Symptoms of inflammation or infectionMalignant neck masses with necrosis and skin involvement may mimic invasion Associated symptomsDysphagia, odynophagia, otalgia, hoarseness, oral cavity pain, nasal obstruction, epistaxis Suggests UADT malignancyB symptoms fever, weight loss & night sweats

Risk factors MalignancyTB exposureCat scratch

Keep the differential diagnosis in mind

History Past medical history Skin cancerUADT malignancy SarcoidosisFungal infectionDental caries/dental work Trauma to head and neck Family historyThyroid cancerParagangliomas

History- Risk Factors for MalignancyTobacco Cigarettes, chew, betel nut, cigar

Alcohol Two together are synergistic

VirusesHPV- oropharynx cancerEBV- nasopharynx cancersHIV- kaposis sarcoma, lymphoma

Immunosupression Transplant patients- Skin cancers, head and neck cancer

OccupationalWood working, leather work paranasal sinus cancer

Risk Factors ContdPrevious head and neck cancer Develop second cancer in 18% of patients

Radiation exposure Salivary gland cancers, thyroid cancer, head and neck sarcomas

Autoimmune disordersSjogrens syndromelymphoma of salivary glandsHashimotos thyroiditisthyroid lymphoma

Physical ExaminationNeck massLocation SizeFirmnessFixationPulsatilePresence of other neck masses or enlarged nodesMovement 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 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

Fine Needle Aspiration Diagnose most head and neck cancers

Suspect lymphomaSend for flow cytometry

Cystic neck massSend washingsStain for thyroglobulin

Still a role for FNA in infectious and inflammatory disorders C & SPresence of pus does not necessarily exclude malignancy Squamous cell carcinoma can present with necrotic nodes

Open BiopsyAlmost NO role in the initial work-up of a neck mass

ContraindicationsPulsatile massesParotid 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 BiopsySituations in which may be indicated Lymphoma FNA is suspicious for lymphoma & further tissue neededCystic neck mass FNA often inconclusiveSend 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 dissectionMake the incision in line with potential incision one would use if further neck surgery is required

Diagnostic Imaging Plain films Limited roleCXR

Ultrasound/DopplerUseful noninvasive testVascularitySolid vs Cystic Sensitive for adenopathyGuided FNACT scan & MRI Location Relation to other structuresVascularity Bone invasionMRI for soft tissue TongueNo dental artifactMRA/MRV

MRI Soft tissue No dental artifact oral & oropharynxBone invasion

CT scansBone imaging Soft tissue imagingDental artifact

The Pulsating Neck MassDifferential DiagnosisNon-vascular mass situated near carotid artery Carotid body tumor (paraganglioma)Carotid artery aneurysm

Work-upImage 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 CystPresentationMay 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 infectionClassic sign is rising with tongue extrusion

DiagnosisHistory & Physical Imaging

Thyroglossal Duct Cyst CautionsMay have papillary ca arising in thyroglossal duct cyst rare but I perform FNACystic 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 CystPresentation mass along the anterior border of the SCM +/- a sinus tractSmooth 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 TumorCarotid body tumors (Paraganglioma)Arise from carotid body located at bifurcation between ICA & ECA Familial in up to 30%Bilateral or multiple

DiagnosisClassic imaging characteristics Vascular mass splaying ICA and ECA lyres signMRI get salt & pepper pattern from the flow voids

Carotid Body TumorTreatment Excision Proximal and distal control of CAPrepared to bypass

ComplicationsVascular injury StrokeCN injury CN IX,X,XII

Squamous Cell Carcinoma FNA Dx of SCCPrimary detectedNo Primary identified; Aka unknown primaryStage tumorTreat primary tumorTreat neck 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 Primary Identified

Squamous cell carcinomaGeneral Management PrinciplesStaging 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, +/- nasopharynxUsed for cancers of larynx, hypopharynx and +/- oropharynx Assess the extent of the tumor & surgical resectabiltyObtain biopsy specimens Assess for 2nd primary

Squamous cell carcinomaGeneral Management PrinciplesTreatment OptionsSurgeryRadiationChemotherapy Combination of bothRads or chemo can be given pre- or post op

Treat the primary site and the cervical lymph nodesTry 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 ratebased on literatureEarly stage disease often similar Advanced disease usually combinationQOL and morbidityOrgan preservation (larynx, hypopharynx)Preserve form and function (oropharynxSwallowing, speech, cosmesis

Goals of TreatmentCureLocal regional control Survival

PalliationPainBleedingCosmesis

Squamous cell carcinomaGeneral Management PrinciplesOral cavity surgeryOropharynx (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

AdenocarcinomaFNA diagnosis of adenocarcinoma in the neck from a distant siteLung, breast, GI, GUMay 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 esophagusNeck dissection - Only if primary site is controlled and patient is potentially curable

Salivary Gland MassesMajor Salivary GlandsParotid- 80% (80%benign:20%malignant)Submandibular 15% (50:50)Sublingual (40:60)

Minor Salivary GlandsOral cavity/ oropharynxLarynxNose & paranasal sinuses

ClassificationHemangiomasVascular malformationsLymphatic malformations1st Branchial cleft cyst

ClassificationHIV TBAtypical TBActinomycosisCat-Scratch ToxoplasmosisTularemiaFungal

History & Physical ExamMajority of neoplasms (benign or malignant) present as asymptomatic swelling

Risk factors for malignancyMajority idiopathicIonizing radiationSjogrens syndrome LymphomaSkin cancers

Clinical Presentation of CancersPain Fixation & invasion of surrounding structures i.e. dermis, mandible TrismusFacial nerve paralysisAdenopathy

Facial Nerve Paralysis with a Parotid MassVery rarely occurs with benign tumors12% to 15% parotid malignancies will exhibit facial paralysisPathologiesAdenoid cystic carcinomaPoorly differentiated carcinomaSCC

Lab TestsSerology if suspect auto-immune process

Biopsy FNA mainstay Open biopsyVery 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 positiveSensitivity 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 diseaseRates 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 ImagingUltrasoundIdentifying a massGuide FNAAssessing 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 MRIMain modalities for imaging parotid neoplasms

Value of Imaging Know what you are getting intotip of iceberg with deep lobe involvementApproach

MalignancyResectabilitySkull baseStructures requiring resection Nodal statusFacial nerve statusAdenoid cystic carcinoma- proximal portion

Common PathologiesBenign Pleomorphic adenoma Malignant degeneration into carcinoma ex-pleomorphic adenoma in 2-10% of pleomorphic adenomasWarthins tumor10% bilateral Malignant Mucoepidermoid carcinomaAdenoid cystic carcinomaMetastases from skin cancers

Prognostic Factors with MalignancyHistologyHigh Grade Malignancies Older AgePain at presentationStage of primary tumor & nodal metastasesSkin invasionFacial nerve dysfunction Peri-neural growthPositive margins

Malignant Secondary NeoplasmsDirect extensionCutaneous SCC/BCC

Lymphatic metastasesSCCMelanoma

Hematogenous MetastasesLung, Kidney, Breast

Direct extensionMetastatic SCC

Factors in Decision MakingPatient factorsAge Co-morbiditiesPatients concerns

Tumor FactorsHistology Benign vs malignantDo you have a diagnosis & how certain are weGrowth rate Risk factors for malignancy

SurgeryMajority can be managed with a superficial parotidectomySubtotal parotidectomyInvolvement of deep lobe Parotidectomy and transcervical approach to parapharyngeal space tumours

Surgical ComplicationsTemporary VII nerve paresis=21%Freys syndrome=6%Infection=3.6%Hematoma=2.7%Hypertrophic scar=2.4%Seroma=0.8%Salivary fistula=0.4%

Indications for Post-operative RadiotherapyHigh grade cancersRecurrent cancersGross or microscopic residual diseaseRegional lymph node metastasesEvidence of locally advanced tumors

Thyroid Cancer

Epidemic of Thyroid Cancer3.6 per 100 000 in 1973 8.7 per 100 000 in 2002represents 2.4 fold increaseDavies, L. et al. JAMA 2006;295:2164-2167.

Thyroid MalignanciesWell-Differentiated Carcinomas (80-85%)Papillary Thyroid Carcinoma (PTC)Follicular Thyroid Carcinoma (FTC)Medullary Thyroid Carcinoma (5-10%)Anaplastic Thyroid Carcinoma (5-10%)Other malignanciesLymphomasDistant Metastases

Well-Differentiated Thyroid Carcinoma Papillary Thyroid CA75-80% of thyroid carcinomasFrequently MultifocalDx on FNA or FSCommon Nodal DzInfrequent Distant DzSlightly Better PrognosisFollicular Thyroid CA5-10% of all thyroid carcinomasmore aggressive natural historySolitary LesionDx on final pathInfrequent Nodal DzCommon Distant DzSlightly Worse Prognosis

Medullary Thyroid CarcinomaC - cell/parafollicular cell originMay be sporadic/nonfamilial (80%) or familial (20%)Familial formsMedullary thyroid carcinoma aloneMEN 2A (Sipples)MTC, Pheochromcytoma, HyperparathyroidismMEN 2BMTC, Pheochromocytoma, Mucosal Neuromas, Mutations on chromosome 10 for the RET proto-oncogeneRegional lymph node metastases - 50% Distant metastases

Medullary Thyroid CarcinomaDiagnosis / ScreeningPentagastrin Stimulation with measurement of calcitonin levelsRet proto-oncogene screeningPatients who screen positive should undergo early thyroidectomyEarly intervention has resulted in 85% DFS at 15-20 yearsSerum calcitonin levels are used as a tumor marker in follow-up

Medullary Thyroid CarcinomaTreatmentexclude pheochromocytomatotal thyroidectomycentral compartment lymphadenectomyelective lateral neck dissection for patients with palpable thyroid diseasetherapeutic lateral neck dissection for patients with palpable neck diseaseTreatmentAdjuvant external beam radiation may be used to enhance locoregional controlThe role of chemotherapy remains to be defined

Anaplastic CarcinomaRare tumor noted for its rapid growth and nearly uniform lethal natureTypically develops in a pre-existing well differentiated thyroid carcinoma or a goiterPoor prognostic factorsAdvanced agePresence of regional or distant metastases

Lymphoma of Thyroid Gland

Thyroid NodulesApproximately 95% of thyroid nodules are benign4-7% of adults have thyroid nodulesWomen > menLikelihood of malignancy=5%Malignancy in clinically apparent nodules=20%

Work-up of Thyroid NoduleHistoryexposure to ionizing radiationfamily history of thyroid carcinoma or other endocrine neoplasms (MEN syndromes)

Physical examinationVocal cord paralysisFixed and firmCervical nodes

InvestigationsFNAThyroid U/STSH

No role for calcitonin, thyroglobulin and thyroid scintigraphy in the initial work-up

FNA (R-A)Repeatedly Nondiagnostic (R-A)Cystic noduleSolid noduleObservation or surgerySurgery strongly consideredSuspicious for papillary ca or Hurthle cell neoplasmSurgery (R- A) Indeterminate Cytology (suspicious, follicular lesion or neoplasm)Follicular lesion Benign Follow (R-A)Thyroid scan HotCold (R-B) FNA

Risk-group DefinitionsAGESA age (> 40)G gradeE extent of tumor extrathyroidal invasiondistant metastasesS size

Other TNM & MACIS AMESA age(M>40,F>50)M metastases (distant)E extent of tumorS size

TreatmentSurgeryPost-operative radioactive iodinePost-operative thyroid suppressionExternal beam radiationPost-operative screening

Total vs Less than Total ThyroidectomyEliminates all cancer and potential cancer (up to 50% CL)Allows RAIAllows monitoring with thyroglobulinDeals with tall cell and insular Ca & prevents transformation of PTC to anaplastic caNo compelling evidence for survival advantageDifficult for RAIThyroglobulin not possibleSpares the parathyroids & RLN

Hemi vs Total ThyroidectomyLow risk diseaseControversialR.R decreased with total thyroidectomySome studies shown no difference

High risk patientsLocal & regional RR lower in total thyroidectomyPossibly improved cause specific survival

Complications of ThyroidetcomyHypoparathyroidismTemp vs Permanent

Recurrent Laryngeal Nerve InjuryUnilat vs bilatTemp vs Perm

ComplicationsPost-operative hematomaConcern re: airwayPrevent obstruction with incomplete strap muscle reapprox inferiorlyDrains do not prevent ManagementAirway emergency Open at bedside if patient in resp distress To OR

Neck ManagementClinically negative neck no neck dissectionNodal metastases at presentationDo not adversely affect survivalDoes increase risk of locoregional recurrence80% of nodal metastases are central compartmentLateral ND only if clinically positive nodes or identified intra-op Functional neck dissection level II-VSpare IJV, SCM, CN XI, cervical plexus

Radioactive Iodine Agent - I131EffectGoal of therapyScanThyroid ablationTherapeuticComplicationsShort termLong term

Radioactive Iodine Only useful in cases of well differentiated thyroid malignanciesResultsOverall efficacy difficult to clearly delineateStudies have shown decreased locoregional recurrences and increased survival in some seriesLess efficacious in unresectable diseasePulmonary 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 womenNo 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 pointRemains stable or diagnosed in 2nd half of pregnancysurgery may be performed after delivery Low TSHif persists after 1st trimester thyroid scan after pregnancy

Among solitary nodules with in determinant (suspicious, follicular neoplasm or Hurthle cell neoplasm) risk of malignancy is ~ 20%Procedure of choice in the evaluation of a thyroid nodule (Recommendation A)

Evaluation is the same except no RAI scan