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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 
EDUCATION Head and Neck   Lumps and Bumps
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
© Vincent Tan ENT
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)
© Vincent Tan ENT
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
© 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.
© Vincent Tan ENT An ultrasound of the neck in progress, with the red arrow showing the probe © Vincent Tan ENT Ultrasound-guided Fine-needle aspiration cytology (FNAC) of a thyroid gland mass (red arrow) Ultrasound-guidance showing the tip of the needle (red arrow) in the mass in question confirming accurate targeting Ultrasound-guidance showing the shaft of the needle (red arrow) in the mass in question confirming accurate targeting
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D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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