Head and Neck Mass - Tripod.commembers.tripod.com/n_aludino_gsj/s/CPD/2006... · – Chromosomal...
Transcript of Head and Neck Mass - Tripod.commembers.tripod.com/n_aludino_gsj/s/CPD/2006... · – Chromosomal...
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Head and Neck Mass(Non-thyroid)
Nolan Ortega Aludino, M.D.Department of Surgery
Ospital ng Maynila Medical Center
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General Data
Y.B.4-year-old
FemaleSta. Mesa
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Chief Complaint
“Neck Mass”
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History of Present Illness
7 months PTC patient’s mother noted a2cm x 2cm mass at thelateral aspect of theneck, left.
with no other associatedsigns and symptoms
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Past Medical History
• Born to a 23-year-old G3P2 via NSD at Health Center with no fetomaternalcomplications.
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Past Medical History
• Immunization: (+) BCG, DPT x 3, OPV x 3, MMR, Hepa B x 3
• no previous surgeries, no known allergies, no bronchial asthma
• March 2005: Primary Koch’s infection; completed 5 months anti Koch’s therapy
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Family History
• (+) Hypertension – Grandmother• (+) DM – Grandmother
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Review of System
• Unremarkable
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Physical Examination
General Survey: conscious, coherent, not in distress
Vital Signs: CR: 110 bpm RR: 22 cpmT: 37.4˚C
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Physical Examination
HEENT:Supple neck
no tonsillopharyngealcongestion
no oral mass/lesion noted
no cervicolympadenopathies
6 x 8 cm mass noted at the supraclavicular area, posterior to the sternoclaedomastoid, non hard, movable, bluish discoloration
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Physical Examination
Chest and Lungs: symmetrical chest expansion, no retractions, no lagging, clear and equal breath sounds
Cardiac: normal rate, regular rhythm, no murmur
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Physical Examination
Extremities: Grossly normal, full and equal pulses
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Salient Features
• 4-year-old• Female• Neck mass
– Lateral– Non-hard– Movable– Bluish discoloration
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LATERAL NECK MASS
Bone Skin Soft Tissue
Vascular/Lymph
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Bone
Mass is non hard and movable
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Skin
Not fixed to overlying skin
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Soft Tissue
Bluish discoloration
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Vascular
• Non hard
• Bluish discoloration
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Lymph
• Non hard
• Bluish discoloration
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Vascular/Lymph
Vascular/LymphInflammatory
Absence of s/sx of inflammation
• Non hard• Bluish
discoloration
• Vascular and lymph malformation
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Clinical Diagnosis
40
60
Degree of Certainty
ObservationHemangiomaSecondary
MedicalSurgical
LymphangiomaPrimary
TreatmentDiagnosis
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Paraclinical Diagnostic Procedure
• Do I need to perform a paraclinicaldiagnostic procedure?
“YES”
• Goals:– To increase the certainty of primary clinical
diagnosis.– To aid in treatment plan
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Not available
Php 10,000minimalHighest
degree of sensitivity
MRI
availablePhp 3,000Radiation
Sensitive enough to determine extent of disease
CT scan
availablePhp 400minimalCystic vssolidUltrasound
AvailabilityCost Risk Benefit
Paraclinical Diagnostic Procedure
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Paraclinical Diagnostic Procedure
• CT Scan– cystic mass with multiple septations, lateral
aspect neck, posterior to the sternocleidomastoid, with no intrathoracicextension
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Pre-treatment Diagnosis
10%
90%
Degree of Certainty
ObservationHemangiomaSecondary
SurgicalMedical
LymphagiomaPrimary
TreatmentDiagnosis
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Goals of Treatment
• Resolution of the mass• Prevent complication
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Treatment Options
Available(+)InfectionHigh
recurrence rate
Aspiration
Not available(++)Lymph-
angiosarcomaLow success
rateRadiotherapy
Not Available(++)
Injury to adjacent
structures
Low success rateSclerotherapy
AvailabilityCost Risk BenefitMedical
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Treatment Options
available(+)AnesthesiaMR: 3%
RR: 6-35%Excision
AvailabilityCost Risk BenefitSurgical
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Treatment Plan
Surgical:Excision
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Pre Operative Management
Secure consentPsychosocial supportOptimize patientPrepare materials
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Operative Technique
• Patient supine under GA• Asepsis and antisepsis• Sterile drapes placed• Oblique incision placed over the mass• Superior and inferior skin flaps created• Platysma cut and opened
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Operative Technique
• Incision done along the anterior border of the sternocleidomastoid muscle.
• Excision of the mass done using sharp and blunt dissection
• Intraoperative findings noted
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Operative Technique
• Intraoperative findings:– well defined capsule containing clear serous
fluid. No extension nor invasion to other structures noted grossly.
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Operative Technique
• Correct sponge, needle and instrument count done
• Hemostasis• Layer by layer closure• DSD
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Final Diagnosis
Cystic Hygroma, lateral aspect, neck, left
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Post-operative Management
First POD DAT
shifted to oral medications:
Paracetamol 250mg/5ml 5ml q4 for pain
Third POD patient discharged
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After Managing the Patient
• I HAVE DISCHARGED MY PATIENT :– IMPROVED– FREE OF COMPLICATIONS
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Discharge Advise
• Daily wound care• Ff up at Surgery OPD after 1 week• Possibility of recurrence
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Sharing of Information
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Sharing of Information
Cystic Hygromas– multiloculated cystic structures– Benign– result of budding lymphatics
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Sharing of Information
– may occur anywhere in the body• neck (75%)• axilla (20%)
– frequently abut and/or encompass neurovascular structures
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Sharing of Information
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Sharing of Information
– Surgical excision remains the therapy of choice
– usually is performed shortly after diagnosis
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Sharing of Information
The different types1.Lymphangioma circumscriptum
– simplex superficial red macular or vesicular lesion of mucous membranes or skin.
2.Lymphangioma capillary– simplex lesion of dilated capillarylike
channels
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Sharing of Information
3. Lymphangioma cavernosa– simplex lesion of dilated lymphatic channels
with deep extension and without cyst formation
4. Lymphangioma cystica (ie, cystic hygroma)
– composed of large lymphatic cysts that expand into adjacent soft tissue planes and are well defined, circumscribed, or lobulated.
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Sharing of Information
5. Lymphangioma complex– composed of multiloculated poorly defined
cysts extending to more than one anatomic area, tissue plane, or organ system.
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Sharing of Information
Medical complications– Airway obstruction– Hemorrhage– Infection– Deformation of surrounding bony structures or
teeth if left untreated
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Sharing of Information
Complications of surgical excision:– Damage to a neurovascular structure– Chylous fistula– Chylothorax– Hemorrhage
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Sharing of InformationMedical therapy: • Alternate therapy
– proposed as the primary treatment for lymphangiomas, particularly for sensitive areas (eg, the orbit) and, more commonly, for recurrent disease after surgical therapy.
• Radiation therapy– effective but abandoned because of later malignant
transformation or retardation of growth sites• Carbon dioxide laser therapy
– has been effective in managing upper airway lesions.
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Sharing of Information
• Intralesional sclerotherapy– group A Streptococcus pyogenes of human
origin (OK-432)– triamcinolone, cyclophosphamide, bleomycin,
fibrin glue, and alcohol for hygroma reduction;
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Sharing of Information
Associated with the following congenital disorders:– Turner syndrome– Chromosomal aneuploidy– Hydrops fetalis– Down syndrome and other trisomy disorders– Fetal alcohol syndrome– Noonan syndrome– Several other congenital syndromes
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References1. Ozen IO, et al., Surgical treatment of cervicofacial cystic
hygromas in children. ORL J Otorhinolaryngol Relat Spec.2005;67(6):331-4. Epub 2005.
2. Fernandez, G., Schwartz, R., Lymphangioma, eMedicine, 2004.3. Neville H., Poole, M., Cystic Hygroma, eMedicine, 20064. Tewfik, T., Yoskovitch A., Congenital Malformations, Neck,
eMedicine, 2006.5. Lin, R., Schwartz, R., Arterial Vascular Malformations Including
Hemangiomas and Lymphangiomas, eMedicine, 2006.6. Fabian, R., Cervicofacial Lymphangiomas, eMedicine, 2006.
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MCQ #1
1. This type of lymphangioma is composed of a simplex lesion of dilated lymphatic channels with deep extension and without cyst formation.
A. Lymphangioma circumscriptumB. Lymphangioma capillaryC. Lymphangioma cavernosaD. Lymphangioma cystica
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MCQ #1
1. This type of lymphangioma is composed of a simplex lesion of dilated lymphatic channels with deep extension and without cyst formation.
A. Lymphangioma circumscriptumB. Lymphangioma capillaryC. Lymphangioma cavernosaD. Lymphangioma cystica
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MCQ #2
2. The following agent is not for sclerotherapy as treatment for cystic hygroma.
A. AlcoholB. CyclophosphamideC. BleomycinD. β Hemolytic Streptoccocus
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MCQ #2
2. The following agent is not for sclerotherapy as treatment for cystic hygroma.
A. AlcoholB. CyclophosphamideC. BleomycinD. β Hemolytic Streptoccocus
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MCR #1
3. Lymphangioma is associated with the following congenital disorder.
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Turner syndrome2. Chromosomal aneuploidy3. Hydrops fetalis4. Boonan syndrome
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MCR #1
3. Lymphangioma is associated with the following congenital disorder.
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Turner syndrome2. Chromosomal aneuploidy3. Hydrops fetalis4. Boonan syndrome
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MCR #2
4. This/these type(s) of lympangioma(s) have cysts which are well defined, circumscribed, or lobulated.
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Lymphangioma circumscriptum2. Lymphangioma capillary3. Lymphangioma cavernosa4. Lymphangioma cystica
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MCR #2
4. This/these type(s) of lympangioma(s) have cysts which are well defined, circumscribed, or lobulated.
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Lymphangioma circumscriptum2. Lymphangioma capillary3. Lymphangioma cavernosa4. Lymphangioma cystica
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MCR #3
5. This/these type of treatment has been most effective in treating lymphangiomasin the upper airway
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Sclerotherapy2. Radiation therapy3. Surgery4. Carbon dioxide laser therapy
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MCR #3
5. This/these type of treatment has been most effective in treating lymphangiomasin the upper airway
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Sclerotherapy2. Radiation therapy3. Surgery4. Carbon dioxide laser therapy