耳鼻咽喉 - 头颈外科学 Neck Masses
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.
Anatomical Considerations Prominent landmarks Triangles of the neck Lymphatic levels
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
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
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
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
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
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
Lymphatic nodal leveles/regions Level II: Contains the upper jugular lymph nodes extends from the level of the hyoid bone to the skull base.
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 ).
Lymphatic nodal leveles/regions Level IV: Contains the lower jugular lymph nodes from the cricothyroid membrane to the clavicle.
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.
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.
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
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
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
Approach of the neck mass History Physical examinations Image studies FNAB and Biopsy
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.
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.
Diagnostic Steps History Physical Examination Empirical Antibiotics Diagnostic Tests
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
Diagnostic Steps Empirical Antibiotics 抗生素经验治疗 Inflammatory mass suspected Two week trial of antibiotics Follow-up for further investigation
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
Diagnostic Tests- Ultrasonography Ultrasonography Useful in differentiating solid from cystic masses and congenital cysts from solid lymph nodes and glandular tumors.
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.
Diagnostic Tests- MRI MRI Similar information as CT Better for upper neck and skull base Vascular delineation with infusion
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
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
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.
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
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
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
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
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
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
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
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
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
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
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
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