Head Neck Lump

FNAB for neck mass

· I use a 22g needle attached to a 20mL syringe with a handle control device

· I apply 1% lignocaine to skin using a 25G needle raising a small bled to reduce discomfort of multiple needle insertions

· I repeat sampling 3 times when a cytopathologist is not examining the slides and commenting immediately in adequacy

· Using the non-dominant hand to palpate and fix the mass the needle is inserted

· After the mass is engaged I rapidly pull the plunger back

· With constant suction applied I move back and forward varying the angle slightly to obtain more solid tissue

· I release suction and withdraw the needle

· I remove the needle from the syringe and fill the syringe with air and then expel the tissue onto a pre-labelled microscope slide

· I make a smear by rubbing a second clean side onto the first

· I place both sides quickly into ethanol

· I then rinse the needle and syringe in ethanol and collect the ethanol for a cytospin.

What do you do if the sample is insifficent for diagnosis

· I would get the FNA repeated by a more experienced surgeon or cytopathologist who is able to examine the sample immediately

· I would consider US-guided sampling if the lesion is difficult to palpate

· Only after discussing the case in an MDT would I recommend open surgical biopsy by a head and neck surgeon who is able to proceed to neck dissection if frozen section is positive for SCC.

 

How do you perform an excisional cervical LN biopsy

You are asked to do an excision biopsy of a 44 year old man with an isolated enck mass at the posterior border of SCM where the FNA is non-diagnostic. What do you do?

· Excision neck node biopsy should not be performed where epithelial malignancy (SCC) is likely and the surgeon is not capable of doing radical neck dissection operations.

· The patient should be referred to a head and neck MDT for further treatment.

In this scenario (male smoker >35 with hard LN) a frozen section should be sent and neck dissection perform immediately if SCC is found.

· Re-operation is much more difficult if the planes have been disturbed by previous excisional node Bx.

You are asked to do an open biopsy of a mass suspected clinically and on imaging of residing in the parotid

Parotid masses should not be subject to excision Bx. Rather superficial parotidectomy should be performed

You are refered a 22 year old non-smoker with an 4cm node in the posterior triangle. The FNA showed lymphoytes bit was not diagnostic.

Here excision biopsy may be appropriate. Other imaging should be assessed for evidence of lymphoma or TB. Mantoux should be performed and serology for EBV tested.

You proceed with the biopsy on the advice of a head and nek surgeon and haematologist. How do you perform the procedure?

· Lesion marked on skin. Landmarks drawn in anaestheic bay

· GA.  Never LA

· Supine. Head ring. Head turned to opposite side. Prep and drape from corner of mouth to midline and as far posteriorly as possible. Sponge in gap between neck and shoulders.

Planning of skin incision: I try to use an incision that could be incorporated into subsequent MRND

I bare in mind the  position of critical structures:

Spinal accessory nerve:

· Incision in skin horizontal 1cm either side of mass with 11 blade.

· Use skin hooks to elevate skin and deepen through skin and platsyma using diathermy.

· I insert a small self-retaining retractor

· I Palpate the lesion and make an assessment of its depth and overlying structures.

When dissectin near a potentially critical structure I use blunt dissection with an artery spreading in the expected direction of the nerve

· Commonly the SCM muscle overlies the node.

· Here I divide the investing layer of fascia in line of skin incision and retract the muscle to expose the LN

· I avoid handling the node. I instead try to manipulate it by grasping the fascia covering it with Debakey forceps.

· I avoid diathermy directly on the node to avoid distorting the pathology with cautery artifact.

· I incise the fascia on the surface of the node with scalpel and place a curved artery between the node and the fascia and gently spread the tips of the artery. I divide the tissue with scissors and use diathermy to cauterize any vessels on the fascia that are bleeding.

· I work my way round the node to expose its deep surface

· There is often a small feeding vessel

· Here visualization of surrounding structures is critical.

· I do not cut tissue that its clealy safe. If visualization is poor I get another assistant, change the light or extend the incision.

· I place an artery on the feeding vessel and ligate with 2/0 Vicryl if large

· I remove the node and place a ray tech in the wound.

· I obtain complete haemostasis, flatten the operting table and ask for a valsalva manoeuvre.

· I close the deep fascia if opened with 2/0 vicryl, platsyma wth 2/0 Vicryl and skin with 4/0 Monocryl.

· I handle the pathology specimen myself and alter the lab that it is coming.

· I divide the node in half and palce half in a container filled with saline and half is sent fresh for microbiology. The tissue is sent immediately to the lab. If the lab is closed, I place half in saline and palce it in the fridge until morning and the other half in formalin.

 

What are the important structures that must be preserved

Marginal mandibular branch of facial nerve:

· Always make incision at least 3cm below the mandible. Dissect onto the fascia of the gland and raise it with the skin flap to avoid subplatsymal flaps (the plane in which the nerve resides)

Spinal accessory nerve:

· The greater auricular nerve emerges from the posterior border of SCM at about its mid-point (Erb’s point). The accessory nerve emerges from posterior border of SCM within 2cm above Erb’s point in 90% of cases. Here it is not covered by platsyma (which is absent) and is very superficial. It runs down to pass under trapezius 4cm above the clavicle.

· XI traverses level V (Posterior triangle)

XI may be encountered when performing biopsy of lesions in level II (under SCM) running obliquely from deep to posterior belly of digastric, over the IJV to penetrate the undersurface of SCM.

· The hypoglossal nerve traverses levels I and II deep in the neck

· The vagus nerve runs deeply between the jugular and carotid

· The thoracic duct lies deep in the inferomedial aspect of left supraclavicular fossa

Deep to the deep fascia in the supraclvicular fossa are the phrenic nerve and brachial plexus.

· I maintain a mental inventory of each of these critical structure and dissect with great care and blunt dissection in the line of the expect structure when in the region.

What are the complications

· Immediate

Bleeding causing haematoma or in most severe cases airway comporimse from expanding neck mass.

Cranial nerve injury: most commonly XI (shoulder droop) or Marginal mandibular (drooping corner of mouth).

· Early: Infection.

· Late: making subsequent MRND difficult from inappropriate open biopsy.

increasing risk of recurrence of cancer