Investigation and management of the neck lump

A neck lump is a common presenting sign in both the paediatric and adult population and may represent a broad range of benign or malignant diagnoses. The appropriate initial assessment, investigation and management is key to delivering appropriate treatments and to avoid missing potentially serious diagnoses. There is a range of imaging modalities available to the treating clinician and huge variability in the appropriate surgical or non-surgical management of disease. In this article we discuss the approach to the assessment of patients with a neck lump, including the history and examinations which should take place. We discuss the imaging modalities which are most appropriate for each condition and the range of management options available. Both common and rarer diagnoses are discussed through the course of the review.     

Advances in diagnostic modalities to detect occult lymph node metastases in head and neck squamous cell carcinoma

Regional metastasis is a prominent feature of head and neck squamous cell carcinoma (HNSCC) and is an important prognostic factor. The currently available imaging techniques for assessment of the neck have limitations in accuracy; thus, elective neck dissection has remained the usual choice of management of the clinically N0 neck (cN0) for tumors with significant (≥20%) incidence of occult regional metastasis. As a consequence, the majority of patients without regional metastasis will undergo unnecessary treatment. The purpose of this review was to discuss new developments in techniques that potentially improve the accuracy of the assessment of the neck in patients with HNSCC. Although imaging has improved in the last decades, a limitation common to all imaging techniques is a lack of sensitivity for small tumor deposits. Therefore, complementary to improvements in imaging techniques, developments in more invasive diagnostic procedures, such as sentinel node biopsy (SNB) will add to the accuracy of diagnostic algorithms for the staging of the neck. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1829–1839, 2015     

Management of neck lumps--a triage model

We report our experience in the out-patient triage of 100 patients presenting with a lump in the neck. The out-patient visit consisted of a general history and examination, assessment of the upper air and food passages and, where indicated, ultrasound and core needle biopsy of the lump. Other investigations were performed as appropriate. One hundred neck lump patients were seen in a 9 month period. Ninety-six of these lumps were diagnosed on an out-patient basis, only four requiring admission for formal excision biopsy. Among the diagnoses were eleven lymphomas, nine parotid neoplasms, nine lymph node metastases, five thyroglossal cysts, and four branchial cysts. Almost half the patients seen had either a reactive lymphadenopathy, or no abnormality. The establishment of a tissue diagnosis on an out-patient basis allowed appropriate referrals to be made and management plans to be formulated. The theoretical risk of seeding of malignant cells in the needle tract is acknowledged and discussed.     

Imaging of the head and neck

Imaging is increasingly being used in the evaluation of patients presenting with a neck mass or with a ‘hot’ neck and has an established role in the staging of head and neck cancer. Plain radiographs have a very limited role and the workhorses of neck imaging are ultrasound, computed tomography (CT) and magnetic resonance imaging with an increased demand, more recently, for positron emission tomography-CT. Contrast studies, videofluoroscopy, angiography and nuclear medicine have a limited but important role in selected cases. This article will discuss the role of some of these imaging modalities in evaluating the soft tissues of the neck.     

On-site cytotechnician evaluation of the adequacy of fine needle aspiration in a neck lump clinic

Introduction

The gold standard for assessing neck lumps is a one-stop clinic with an on-site cytopathologist who can provide an immediate fine needle aspiration (FNA) report. However, this has considerable resource implications and is not available in all units. In our department, surgeons perform FNAs guided by palpation. The FNA is evaluated for specimen adequacy by an on-site cytotechnician. This study evaluated the impact of the cytotechnician on the adequacy of neck lump FNA.

Methods

FNA performed between June 2010 and February 2012 was examined. The FNA performed at a neck lump clinic with an assessment of adequacy by an on-site cytotechnician were considered the test group. All other neck lump FNAs from other sources without an assessment of adequacy by an on-site cytotechnician were considered the control group.

Results

Of the FNAs, 134 met the inclusion criteria for this study. Of these, 87 FNAs (65%) were analysed for adequacy by the on-site cytotechnician and the remaining 47 (35%) were not. The results demonstrated an FNA inadequacy with and without on-site cytotechnician assessment of 29.9% and 40.4% respectively. This is equivalent to an absolute risk reduction of an inadequate FNA of 10.5%, which equates to a number needed to treat of 9.5, ie the cytotechnician needs to assess 9.5 (ie the cytotechnician […] specimen).

Conclusions

In neck lump clinics where on-site cytopathology is not available, an on-site cytotechnician is a compromise measure that does reduce the number of inadequate FNAs.     

Evolving Concepts in the Management of Shoulder Instability

BackgroundShoulder instability exists on a spectrum ranging from subtle subluxation and pain to dislocation and can be the result of a traumatic event or repetitive microtrauma. Shoulder instability can result in significant disability and often requires surgical intervention, especially amongst younger, active patient populations. The optimal treatment of shoulder instability depends on the degree of instability and concomitant pathology involving the labrum, capsule, and bony anatomy of the glenoid and humeral head. Even with surgical intervention, recurrent instability remains a relatively common and difficult problem to address.PurposeWith a focus on anterior instability, the purpose of this review article is to discuss the current assessment and treatment of shoulder instability, and highlight current and future treatment modalities, as well as to identify current trends and deficiencies in our current management. We also provide an algorithm for the surgical treatment of anterior shoulder instability.MethodsLiterature databases were extensively searched for recent articles related to the mechanism, diagnosis, and treatment of shoulder instability to comprise a comprehensive review.Conclusion Although there are multiple treatment modalities available for shoulder instability, such as nonoperative management, open and arthroscopic Bankart repair, Latarjet procedures, and remplissage, orthopaedic surgeons continue to learn about the most appropriate method of management as increasing long-term outcomes become available.     

Caliper measurement to improve clinical assessment of palpable neck lumps

INTRODUCTION

One-stop neck lump clinics with ultrasonography and cytopathology support are an expensive and finite resource. Consequently, many neck lump patients are assessed in general ear, nose and throat or head and neck clinics.Optimal clinical assessment of neck lump size is important to guide investigation, monitor change and provisionally stage nodal disease. The aims of this study were to investigate whether caliper measurement is more accurate than clinical palpation in assessing neck lump size and whether caliper measurement of neck lump size correlates closely with accurate ultrasonography measurement.

METHODS

A prospective study was carried out involving 50 patients with clinically palpable neck lumps presenting to the one-stop neck lump clinic. Long and short axis neck lump dimensions were estimated first by clinical palpation and second by caliper measurement. Estimations were compared with accurate ultrasonography measurement.

RESULTS

The mean combined long and short axis measurement deviation from accurate ultrasonography measurement was smaller for caliper measurement (7.80mm) than for clinical palpation (12.38mm) (p<0.01). There was no significant difference observed between combined axis ultrasonography and combined axis caliper measurement of neck lumps (p=0.462).

CONCLUSIONS

Caliper measurement is more accurate than clinical palpation in estimating the size of clinically palpable neck lumps. The use of calipers to measure the skin surface dimensions of palpable neck lumps is statistically comparable to accurate ultrasonography measurement.     

Acute hyperparathyroid crisis: ectopic submandibular parathyroid gland the culprit

Parathyroid exploration via a focused approach or bilateral neck exploration should be considered in the management of all types of hyperparathyroidism. Eutopic and ectopic, single or multiple glands can pose challenges to the surgeon and available preoperative imaging modalities may not be equally applicable or appropriate in all cases. We report an interesting case of parathyroid surgery where the patient presented with a rare ectopic adenoma in the form of a hyperparathyroid crisis.     

Imaging the spine

The spine is a complex structure composed of different tissues with a wide range of clinical pathologies. There are multiple imaging modalities available at our disposal to image the spine. This article will present several common pathologies and how different imaging modalities have their respective roles in clinching the right diagnosis and aiding subsequent management.     

Adjunctive maneuvers to treat urethral stricture: a review of the world literature

The development of urethral stricture (US) or bladder neck contracture is a relatively uncommon but well described condition observed primarily in men. Despite familiarity with US disease, management remains challenging for urologists. Risk factors for the development of USs or bladder neck contracture include primary treatment modality, tobacco smoking, coronary artery disease and poorly controlled diabetes mellitus. Numerous treatment options exist for this condition that vary in procedural complexity, including intermittent self catheterization (CIC), serial urethral dilation, endoscopic techniques and open reconstructive repairs. Repetitive procedures for this condition may carry increased failure rates and morbidities. For the treatment of refractory or recalcitrant bladder neck contracture, newer intralesional anti-proliferative, anti-scar agents have been used in combination with transurethral bladder neck incisions to augment outcome and long-term effect. The primary focus of this systematic review of the published literature is to streamline and summarize various and newer therapeutic modalities available to manage patients with US or bladder neck contracture.     

Hemangiomas of infancy: treatment of ulceration in the head and neck

Ulceration is a common complication of hemangiomas of infancy and presents a therapeutic dilemma for the head and neck-facial plastic surgeon. Multiple therapies are available, further complicating treatment of patients. We review the common characteristics of ulcerated hemangiomas and discuss the treatment modalities available. We present case reports to illustrate management options and a stepwise algorithm for treatment of ulcerated hemangiomas.     

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence‐based approach. © 2014 Wiley Periodicals, Inc. Head Neck 37: 915–926, 2015     

Methods of evaluating lumbar and cervical fusion

Introduced in 1911, spinal fusion is now widely used to stabilize the cervical, thoracic, and lumbar spine. Despite advancements in surgical techniques, including the use of instrumentation and optimizing bone graft options, pseudarthrosis remains one of the most significant causes of clinical failure following attempted fusion. Diagnosis of this common complication is based on a focused clinical assessment and imaging studies. Pseudarthrosis classically presents with the onset of or return of axial or radicular symptoms during the first postoperative year. However, this diagnosis is complicated because other diagnoses can mimic these symptoms (such as infection or adjacent segment degeneration) and because many cases of pseudarthrosis are asymptomatic. Computed tomography and assessment of motion on flexion/extension radiographs are the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis. The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis.     

Suggestions for diagnosing avascular necrosis of the hip in the 1990s.

Avascular necrosis of the hip is a serious clinical problem encountered by primary care physicians. It requires early detection for proper management and treatment. The clinician should be aware of the imaging modalities available for evaluation of patients with suspected avascular necrosis. Traditional studies include plain-film radiography, computed tomography, and planar bone scintigraphy. Magnetic resonance imaging and single-photon emission computed tomography bone scanning have been developed to such an extent that they are now the most sensitive indicators of early avascular necrosis. The authors review currently available imaging modalities and provide a practical approach to the assessment of patients with suspected avascular necrosis of the hip.     

Imaging of the acute abdomen

Acute abdominal pain is a common presentation in the emergency setting. Radiological imaging techniques play an important role in the diagnosis and management of such patients. In this article we discuss the modalities available and the relative merits and limitations of each.     

Malignant peripheral primitive neuroectodermal tumor-peripheral neuroepithelioma of the head and neck: a clinicopathologic study of five cases and review of the literature

BACKGROUND: The term primitive neuroectodermal tumor (PNET) encompasses a number of neoplasms of common neuroectodermal origin, but of variable clinical, histopathologic, ultrastructural, and molecular characteristics. Here, we focus on one particular member of the PNET family, the malignant peripheral PNET (pPNET) or peripheral neuroepithelioma of head and neck. METHODS: Five patients diagnosed with malignant pPNET-peripheral neuroepithelioma of head and neck were included in the study. All existing literature was reviewed. RESULTS: The diagnosis of malignant pPNET-peripheral neuroepithelioma of the head and neck was confirmed in all five cases. All patients are alive after treatment with a combination of therapeutic modalities; only one patient had metastatic disease develop. A literature review revealed another 38 reported cases. CONCLUSIONS: Malignant pPNET-peripheral neuroepithelioma should be included in the differential diagnosis of small, round, blue cell tumors of head and neck. A combination of multiple diagnostic modalities is essential for correct diagnosis, and multimodality treatment offers the best outcome.     

IS EXPLORATION MANDATORY IN PENETRATING ZONE II NECK INJURIES?

BACKGROUND: A policy of mandatory neck exploration for zone II injuries deep to platysma was promoted in the 1950s and was associated with a reduction in mortality when compared with expectant or delayed exploration. Recently many trauma centres have been practising selective neck exploration using physical examination and imaging to stratify patients to different management strategies. In the Auckland region, patients with penetrating zone II injury deep to platysma have been managed with mandatory neck exploration. As penetrating injuries in the Auckland region are caused by a range of sharp objects, with gunshot wounds rare, outcomes of management of zone II neck injuries in this population warrant investigation. The aim of this study was to determine the rate of therapeutic neck exploration in patients with penetrating zone II neck injury in the Auckland region and to suggest optimum management strategies for such injuries. METHODS: Retrospective audit of all patients presenting to Auckland and Middlemore Hospitals, Auckland, New Zealand, between 1995 and 2005 was carried out. Review of electronic clinical records and operation notes was also carried out. RESULTS: An overall positive neck exploration rate of 25% was obtained (87% for patients with hard signs on physical examination). Physical examination had a sensitivity of 93% and a positive predictive value of 87% in this case series. Neck exploration was not associated with known complications or missed injuries. CONCLUSION: In the Auckland setting, physical examination would appear to be a safe and reliable method for the stratification of patients for either operative or conservative management.     

Nutritional concepts and considerations in head and neck surgery

Assessment and correction of malnutrition is a major contribution to the improvements in the pre- and postoperative management of patients with head and neck cancer over the past 20 years. These patients are often in a poor nutritional status and thereby are at a higher operative risk secondary to the local and systemic effects of the tumor and its treatment. This article reviews current data emphasizing preoperative nutritional assessment, modalities available for nutritional therapy in head and neck cancer patients, and indications for perioperative use of these modalities.     

Managing voiding dysfunction in young men

Voiding dysfunction is an uncommon condition in young men. With increased understanding of the etiology of chronic lower urinary tract dysfunction, there has been significant improvement in the management of the condition. We have reviewed the current literature and make suggestions about diagnosis, treatment, and further research on this topic. We searched the PubMed database for the management of voiding dysfunction in young men using the following terms: voiding dysfunction, lower urinary tract symptoms, young men, risk factor, urodynamics study, uroflowmetry, magnetic resonance imaging, primary bladder neck obstruction/bladder neck dysfunction, dysfunctional voiding/pseudodyssynergia, impaired detrusor contractility/detrusor underactivity, adrenergic antagonist, transurethral incision, urotherapy, baclofen, and botulinum toxin. Uroflowmetry is an important noninvasive examination for screening young men for possible voiding dysfunction. A videourodynamic study is recommended for patients with low urine flow. Primary bladder neck obstruction and dysfunctional voiding are the two most common diagnoses. α-Adrenergic antagonists and urotherapy are widely used for treating bladder neck obstruction and dysfunctional voiding, respectively. Botulinum toxin A may become a potential therapeutic option in the future. Although the published reports usually included a small number of patients and lacked randomization and a placebo-controlled group, these clinical studies still provide great advances in managing voiding dysfunction in young men. Further well-designed studies are warranted to support optimal management of these conditions.     

Imaging Pediatric Vascular Lesions

Vascular anomalies are commonly encountered in pediatric and dermatology practices. Most of these lesions are benign and easy to diagnose based on history and clinical exam alone. However, in some cases the diagnosis may not be clear. This may be of particular concern given that vascular anomalies may occasionally be associated with an underlying syndrome, congenital disease, or serious, life-threatening condition. Defining the type of vascular lesion early and correctly is particularly important to determine the optimal approach to management and treatment of each patient. The care of pediatric patients often requires collaboration from a multitude of specialties including pediatrics, dermatology, plastic surgery, radiology, ophthalmology, and neurology. Although early characterization of vascular lesions is important, consensus guidelines regarding the evaluation and imaging of vascular anomalies does not exist to date. Here, the authors provide an overview of pediatric vascular lesions, current classification systems for characterizing these lesions, the various imaging modalities available, and recommendations for appropriate imaging evaluation.Vascular anomalies are commonly seen in pediatric patients, with an estimated prevalence of at least 4.5 percent.1 Although typically benign, some vascular anomalies can be part of a syndrome or may be associated with serious, life-threatening conditions. The care of patients with vascular anomalies often requires a multidisciplinary approach. Dermatologists, radiologists, plastic surgeons, neurologists, otolaryngologists, plastic surgeons, hematologists, and pediatricians may all play an integral role in the management of these patients. Defining the type of vascular lesion early and correctly is particularly important in determining the approach to management of the individual patient. This article will discuss an array of pediatric vascular lesions, review the different imaging modalities available, and provide recommendations for imaging based on lesion type.