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1 耳鼻咽喉 - 头颈外科学 Neck Masses

2 Definition The general definition of a neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles.

3 Anatomical Considerations Prominent landmarks Triangles of the neck Lymphatic levels

4 Anatomical Considerations The prominent landmarks of the neck 1. Hyoid bone 舌骨 2. Thyroid cartilage 甲状软骨 3. Cricoid cartilage 环状软骨 4. Trachea 气管 5. Sternocleidomastoid muscles (SCM 胸锁乳突

5 Anatomical Considerations The SCM divides each side of the neck into two major triangles, anterior and posterior. The anterior triangle is delineated by 1. The anterior border of the SCM, 2. The midline, 3. The lower border of the mandible. 下颌骨下缘

The anterior triangle is delineated by 1.

6 Anatomical Considerations The borders of the posterior triangles are : The posterior border of the SCM. The clavicle. 锁骨 The anterior border of the trapezius muscle. 斜方肌

7 Classification of Neck Masses Common Neck Masses Inflammantory Benign leision Malignant tumor 炎性病变良性病变恶性肿瘤 Congenital Benign tumor Metastatic Primary 先天性良性肿瘤转移癌原发恶性肿瘤

8 Lymphatic nodal leveles/regions Developed by Memorial Sloan-Kettering Cancer Center Ease and uniformity in describing regional nodal involvement in cancer of the head and neck

9 Lymphatic nodal leveles/regions Level I: Contains the submental 颏下 and submandibular 颌下 triangles. Bounded by the posterior belly of the digastric muscle 二腹肌后腹 the hyoid bone 舌骨 the body of the mandible. 下颌骨

Bounded by the posterior belly of the digastric

10 Lymphatic nodal leveles/regions Level II: Contains the upper jugular lymph nodes extends from the level of the hyoid bone to the skull base.

11 Lymphatic nodal leveles/regions Level III: Contains the middle jugular lymph nodes from the hyoid bone to the cricothyroid membrane( 环甲膜 ) or omohyoid muscle( 肩胛舌骨肌 ).

12 Lymphatic nodal leveles/regions Level IV: Contains the lower jugular lymph nodes from the cricothyroid membrane to the clavicle.

13 Lymphatic nodal leveles/regions Level V: Contains the lymph nodes in the posterior triangle bounded by the anterior border of the trapezius, the posterior border of the SCM, and the clavicle.

14 Lymphatic nodal leveles/regions Level VI: Contains the lymph nodes of the anterior compartment from the hyoid bone to the suprasternal notch. On each side the lateral border is formed by the medial border of the carotid sheath 颈动脉鞘.

15 Metastasis Location according to Various Primary Lesions Level I Submandibular primary; oral cavity; lip; paranasal sinuses Level II Nasopharynx; oropharynx, maxillary sinus Level III Larynx; hypopharynx; thyroid Level IV Subglottic larynx; thyroid; cervical esophagus Level V Thyroid; cervical esophagus; Level VI Thyroid; larynx

maxillary sinus Level III Larynx; hypopharynx; thyroid Level IV Subglottic larynx;

16 Staging of the neck N classification AJCC (1997) Consistent for all mucosal sites except the nasopharynx Thyroid and nasopharynx have different staging based on tumor behavior and prognosis Based on extent of disease prior to first treatment

nasopharynx have different staging based on tumor behavior

17 Staging of the neck NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: a single ipsilateral lymph node, < 3 N2a: a single ipsilateral lymph node 3 to 6 cm N2b: multiple ipsilateral lymph nodes, none more than 6 cm N2c: bilateral or contralateral nodes < 6cm N3: a lymph node more than 6 cm in greatest dimension

lymph node 3 to 6 cm N2b: multiple ipsilateral lymph nodes, none more than 6 cm N2c:

18 Approach of the neck mass History Physical examinations Image studies FNAB and Biopsy

19 General Considerations Patient age Pediatric (0-15 years): 90% benign. Young adult (16-40 years): similar to pediatric. Late adult (>40 years): rule of 80s. Location Congenital masses: consistent in location. Metastatic masses: key to primary lesion.

20 General Considerations Skandalakis s RULE OF 80% 80% of non-thyroid neck masses in adults are malignant, 80% of these masses are metastastic; 80% of which will come from a primary in the head and neck. RULE OF SEVEN Mass present for seven days is inflammatory. Mass present for seven months is neoplastic. Mass present for seven years is congenital.

21 Diagnostic Steps History Physical Examination Empirical Antibiotics Diagnostic Tests

22 Diagnostic Steps History Developmental time course Associated symptoms (dysphagia, otalgia, voice) Personal habits (tobacco, alcohol) Previous irradiation or surgery Physical Examination Complete head and neck exam (visualize & palpate) Emphasis on location, mobility and consistency

23 Diagnostic Steps Empirical Antibiotics 抗生素经验治疗 Inflammatory mass suspected Two week trial of antibiotics Follow-up for further investigation

24 Diagnostic Steps Diagnostic Tests Ultrasonography 超声 Computed tomography (CT) Magnetic resonance imaging (MRI) Fine needle aspiration biopsy (FNAB) 细针穿刺活检 Biopsy

25 Diagnostic Tests- Ultrasonography Ultrasonography Useful in differentiating solid from cystic masses and congenital cysts from solid lymph nodes and glandular tumors.

26 Diagnostic Tests- Computed Tomography (CT) Computed Tomography (CT): 1. Distinguish cystic from solid lesions. 2. Define the origin and full extent of deep, ill-defined masses. 3. When used with contrast can delineate vascularity or blood flow. 4. Detect an unknown primary lesion 5. To help with staging purposes.

27 Diagnostic Tests- MRI MRI Similar information as CT Better for upper neck and skull base Vascular delineation with infusion

28 Diagnostic Tests- FNAB Any neck mass that is not an obvious abscess Persistence after a 2 week course of antibiotics Small gauge needle Reduces bleeding Seeding of tumor not a concern

29 Treatment of Neck Mass Inflammantory 炎性病变 Surgery Benign leision 手术治疗良性病变 Surgery 手术治疗 Radiotherapy Malignant tumor 放疗恶性肿瘤 Chemotherapy 化疗 Treatment of primary tumor 原发肿瘤治疗

30 Classification of Neck Dissections 颈清扫术的分类 Standardized until 1991 Academy s Committee for Head and Neck Surgery and Oncology publicized standard classification system.

31 Classification of Neck Dissections Academy s classification 1. Radical neck dissection (RND) 根治性颈清扫术 2. Modified radical neck dissection (MRND) 改良根治性颈清扫术 3. Selective neck dissection (SND) 择区颈清扫术 Supra-omohyoid type Lateral type Posterolateral type Anterior compartment type 4. Extended radical neck dissection 颈扩大清扫术

32 颈淋巴结炎 cervical lymphadenitis 头面颈部有炎症时常引起颈部淋巴结感染诊断颈部淋巴结肿大急性期有红肿痛热等特点伴发热和局部压痛慢性期症状轻压痛不明显实验室检查及 B 超帮助诊断必要时作淋巴结穿刺或切除活检治疗抗感染激素穿刺及切开排脓手术等同时处理原发病灶

33 颈淋巴结结核 tuberculosis of cervical lymph nodes 常为原发性或继发于肺腹腔等处的结核病灶诊断单侧或双侧颈淋巴结肿大常呈串珠状与皮肤及周围组织粘连可发生干酪性坏死或破溃形成瘘管不愈淋巴结穿刺或活检确诊治疗以全身抗结核治疗为主局部治疗为辅

34 艾滋病性颈淋巴结肿大是艾滋病早期症状之一颈淋巴结肿大多位于颈后三角区常伴有腹股沟等多处淋巴结肿大发热消瘦乏力白细胞减少等症状诊断综合病史临床表现和实验室检查治疗到相关医疗机构治疗

35 甲状腺腺瘤 adenoma of the thyroid 颈部最常见的良性肿瘤 40 岁左右的女性多见诊断颈前无痛性肿块随吞咽上下运动 B 超放射核素扫描穿刺活检帮助诊断治疗手术切除

36 诊断涎腺混合瘤 mixed tumor of salivary gland 多见于腮腺耳前或耳垂下, 下颌下肿块肿块光滑生长缓慢症状不明显 B 超 CT 和 MRI 可助诊断治疗手术切除

37 恶性淋巴瘤 lymphoma 起源于淋巴造血组织病理学分类复杂诊断以淋巴结肿大为特征颈部是最常受累部位慢性进行性无痛性表浅淋巴结肿大淋巴结穿刺或切除活检确诊治疗首选放疗及化疗

38 转移性恶性肿瘤 metastatic carcinoma 原发灶来自头颈部 - 最多见来自胸腹盆腔原发灶不明诊断根据病史症状相关辅助检查一般体格内镜超声影像放射核素血清学等综合分析确诊靠病理治疗根据原发灶及患者病情的不同采用放疗化疗手术或综合治疗等方法

39 鼻咽癌 Nasopharyngeal carcinoma 发生颈淋巴转移率高有时为患者的首发症状常先转移至颈深上淋巴结晚期转移至颈深下或对侧淋巴结治疗放疗为主局部复发或放疗后残存可手术切除或化疗

40 下咽癌 Hypopharyngeal carcinoma 较易发生淋巴转移早期常转移至同侧颈动脉三角区淋巴结少数转移至气管旁及锁骨上淋巴结治疗下咽癌切除 + 颈清扫术结合放化疗

41 喉癌 Laryngeal carcinoma 以声门上及声门下型多见常转移至舌骨下喉前气管前及颈内静脉周围淋巴结治疗喉癌切除 + 颈清扫术加或不加放化疗

42 Thanks for your attention.

Microsoft PowerPoint - 頭頸部癌症介紹0902WuCheWei

Microsoft PowerPoint - 頭頸部癌症介紹0902WuCheWei 頭頸部癌症簡介 Introduction to Head and Neck Cancer 課程目標 1. 瞭解頭頸部癌症的流行病學 2. 瞭解頭頸部癌症的病徵生理與病理機轉 3. 瞭解頭頸部癌症的預防篩檢及診斷分期 4. 瞭解頭頸部癌症的治療方式及預後腫瘤護理