Vincent ENT, Head and Neck Surgery Specialist Clinic - Klang, Shah Alam, Subang, PJ, KL and more...

Vincent’s S.C.A.N.S

Ear, Nose and Throat (ENT), Head and Neck Surgery

Specialist Clinic

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Last update: 10/5/14

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Part 2 - Diagnosis and Management

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To read from Head & Neck Lumps & Bumps Part 1

The neck lump removed completely after an excisional biopsy -further laboratoey test confirmed a lipoma - a benign lump of fat/adipose tissue origin

If cancer is confirmed, staging of the cancer is mandatory to know the local, regional and distant extent of the disease in order to plan the treatment of the disease. Staging may involve an examination under anaesthesia (in the operating room), radiological imaging procedures and more laboratory tests. What about treatment ? Treatment depends very much on the cause of your lump. Therefore it is extremely important in the very first instance to get the right cells for the best diagnosis ! An initial single course of antibiotics can be prescribed in cases where your swelling is due to infection, usually presenting with fever, painful mass and reddened overlying skin. In children, most neck lumps are caused by treatable infections. However, treatment should start quickly to prevent complications or the spread of infection. Follow-up is advised to ensure the complete resolution of the swelling. In the event an abscess (i.e collection of pus) forms, a formal surgical drainage procedure, known as incision and drainage is necessary and the wound is allowed to heal with regular dressing. Excisional biopsy should be considered when a neck mass persists beyond four to six weeks after a single course of a broad-spectrum antibiotic. Generally, benign neck cysts and masses are usually removed by surgical excision. This can be done under local or general anaesthesia. A watch-and- wait management can also be adopted if the mass is deemed to be benign and malignancy is excluded definitely. As for head and neck cancers, after the cancer is staged, it may be treated by some combination of surgery, radiation therapy, and chemotherapy, depending on their nature and site of disease. Surgery usually involves removal of the primary cancer with neck dissection surgery (surgery to remove lymphatic chain of the neck). Treatment plan may differ between different doctors and centres.

Flexible endoscopy of the upper airway. The black tube represent the scope (source of unlabelled diagram: Netter Atlas of Anatomy) NASAL CAVITY TONGUE POSTNASAL SPACE BRAIN SOFT PALATE HARD PALATE BASE OF TONGUE EPIGLOTTIS WINDPIPE/TRACHEA TONSIL CERVICAL SPINE VOCAL CORDS LOWER JAW/ MANDIBLE POSTERIOR PHARYNGEAL WALL © Vincent Tan ENT Flexible endoscopy of the upper airway in a real ENT clinic setting.

© Vincent Tan ENT LEFT: A patient with a large submandibular salivary gland before surgery. RIGHT: The patient on postoperative day 1 with a surgical drain in place. Laboratory test confirmed the tumour of intermediate nature (i.e with mixed features of both non-cancerous and cancerous growth)

CT scan of the neck sonfirming a large neck mass © Vincent Tan ENT PET CT scan confirming a suspicious large neck mass

3. Radiological imaging eg. ultrasound, contrast-enhanced computed tomographic (CT) scan, magnetic resonance imaging (MRI) scan may be needed to evaluate these masses further. These scans assesses the extent of the swelling. The signal generated (intensity, echogenicity, density), margins of the swelling, it can provide more information about the nature of the swelling. 4 . PET (Positron Emission Tomography) scan which involves injection with a radioactive tracer is useful to identify cancer deposits in the whole body, whether it has spread to other distant organs in the body or the primary site of cancer. It can also be used after treatment to know if the cancer has been fully eliminated or residual cancer deposit still exists somehere elase in the body.

Fine-needle aspiration cytology (FNAC) of a parotid gland mass (red arrow)

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The flexible endoscopy of the upper airway is also called Flexible Naso-Pharyngo-Laryngoscopy (FNPLS in short) as it passes through and visualizes those areas. (naso=nose, pharyngo = throat, laryngo=voice box region) It is an easily-tolerated procedure done in the ENT clinic. Usually a local anesthetic spray would be administered into both nostrils a few minutes before the procedure to reduce the discomfort. Much vital information can be gathered from this endoscopy eg tumour growth, airway compromise and structural infiltration among others. © Vincent Tan ENT

LEFT: A patient with a large neck swelling which had existed for 20 years (!) before surgery. RIGHT: He did not require any surgical drain following the surgery. He also displayed excellent healing properties - that was the wound only 2 weeks after surgery. Laboratory test confirmed the tumour of non-cancerous nature.

( Mouse over to zoom in)

Other investigations may also be necessary to identify the exact nature of your neck mass: 1. Fine-needle aspiration cytology (FNAC) FNAC is the most accurate test for evaluating these swellings Using a syringe with certain manoeuvres and techniques, your specialist will remove some microscopic content from your swelling for further detailed pathological examination in the laboratory. FNAC can be done in the clinic itself. This procedure is usually tolerable and pain is minimal. Under the microscope, the constituting cells collected can be further studied by a pathologist to give more vital information about your swelling. In 80-90% of cases, a confident diagnosis can usually be made. Complications like bleeding or hematoma are very rare. The risk of cancer seeding using FNAC is negligible as evidenced by many years of medical research. Rarely, false-positive (i.e "positive"ly recognised pathology in the absence of actual disease) or false-negative (i.e failure to recognised pathology when in fact disease is actually present) results may also occur. Alternatively, FNAC can be more accurately performed under ultrasound guidance, called ultrasound- guided FNAC. It is more superior for deep-seated masses as the ultrasound allow a real-time precise targeting of the needle into the lesion in question (analogy is a soldier wearing a night-vision infra-red goggle in pitch-black darkness shooting at a target !) The advantages of ultrasonography is that it is rapid, inexpensive, versatile, no ionizing radiation (eg. CT scan, X ray) is applied, does not require injection of contrast medium and can be easily repeated when necessary. Ultrasound guided fine needle aspiration cytology (FNAC) is a safe diagnostic procedure in which any structure visualized can be reached quickly and precisely by a fine needle in any desired plane with constant visualization of the needle tip during insertion. Here in this clinic, FNAC is not done 'blind'. Your surgeon further enhances the accuracy by guiding the needle under real-time ultrasound guidance into the most suspicious part of the swelling in order to obtain the most representative cells.

What will your ENT doctor do? Some of these swellings look the same on the surface even though they may differ significantly in terms of their nature. Therefore your doctor will normally start by asking you more details about your swelling. History of the lump that your doctor is interested in are: • Where is the lump located? • Is it the first time you are having this or is it a recurrent or chronic problem • When did this lump arise ? Since birth, childhood or later in life ? • Has it been growing bigger? Over how many weeks, months or years? • Is there pain ? • Is it a hard lump or relatively soft, pliable, bag-like (cystic) mass? • Is the entire neck swollen or just a specific spot over the neck? • What other symptoms are present eg. discharge ? • Was there any preceding surgery or trauma ? • Do you have compressive symptoms like difficulty breathing, swallowing? • How is your appetite and weight ever since you noticed the swelling? • Any associated symptoms like: o rashes o change of voice ? o growth in the mouth o swollen tongue o blood in the saliva or phlegm o changes in the surrounding skin o persistent ear pain or ear pain while swallowing Your doctor will usually proceed to examine your swelling further. Next, endoscopic assessment via rigid or flexible scope (also called FNPLS-flexible naso-pharyngo-laryngoscopy) to assess the mucosa (inner lining) of your nostrils to the voice box may be necessary to exclude tumour growth or any compression/compromise of your upper aerodigestive tract.

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2. Biopsy - if the swelling is small, your doctor may further advise you to have it fully removed i.e an excisional biopsy. The whole swelling is removed for further detailed pathological examination in the laboratory to arrive at a diagnosis. In rare instances, part (and not the entire) of your swelling is removed i.e incisional biopsy may be necessary for a more definite diagnosis. However, the risk of cancer seeding i.e cancer cells spreading to your skin is much higher. Therefore incisional biopsy is done in very specific conditions only.