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Benign Tumors of
Head and Neck
Dr. Billones
Erik
14
References: Source: Cor Christi batch 2009 and 2011, past powerpoint, recording, past-e
Guys, this is based on batch 2012 ppt. Ayaw kasi bigay ni doc ung new ppt nya.
Items that came out in the past-es are Emphasized.
I encourage everyone to read other references na rin, remember mahirap maging pula ulit ung Evals
results nating lahat. Thats all I ask of you. God bless!
BENIGN TUMORS OF HEAD AND NECK
I. SURGICAL ANATOMY OF THE NECK
Anterior
Submandibular
Carotid
Muscular
Submental
Lateral
Occipital
Supraclavicular
The neck is divided into specific
triangles: anterior triangle and
postero-lateral triangles.
The sternocleidomastoid will divide
. the neck into anterior and posterior
triangle.
Posterolateral
Triangle
Boundaries
Components
submandibular
triangle
digastric muscles
carotid
digastric and
omohyoid
muscular
midline
structures;
thyroid,
strap
muscles,
larynx,
traches, esophagus
submental
submental
nodes
Occipital
nerves
spinal
nerve
Supraclavicular
lymph
such
as
accessory
B. CERVICAL LYMPHATICS
Cervical lymphatics are important in localization of the sites because this will give an idea on what
primary sites to look for.
Superficial
lie near the surface of the neck along the external jugular vein
Superficial anterior and Superficial lateral
perforate the first layer of cervical fascia to empty into the deep cervical lymphatic chain
Although frequently involved by metastasis, especially during the late stages, the superficial
lymph nodes are nevertheless of little significance from a practical standpoint of surgical
treatment.
The reason is that if superficial lymphatics are involved with cancer they cannot be removed
without resection of large areas of skin.
Deep more important
since they receive lymph from the mucous membranes lining the mouth, pharynx larynx, and
major salivary and thyroid glands, as well as the skin of the head and neck.
Accompany the internal jugular vein and their branches or lie within the major salivary glands
Anterior
Submandibular (I)
preglandular
interglandular
prevascular and retrovascular
submental (IB)
Anterior Compartment Group (VI)
Pre-tracheal
Para-tracheal
Pre-laryngeal
Jugular chain (II, III, IV) -> related to IJV
superior jugular (Subdigastric) (II)
o junctional nodes of Finch
middle (III)
inferior (IV)
o prescalene nodal masses
Lateral (Spinal accessory group) (V)
Upper
Middle
Inferior
o supraclavicular group
Left
Thoracic duct
climbs upward and left lateral arch behind the carotid sheath, receives tributaries from the neck,
enters the venous junction between the internal jugular and subclavian veins
Virchows nodes-enlarged, hard, left supraclavicular nodes that may indicate abdominal
malignancy
Multiple lymphatic ducts drain the right side which also drains to the venous system in the right.
Right
Multiple lymph vessels (right lymphatic duct)
0-15
CONGENITAL
Vascular lesions (AT)
Branchial cyst (AT)
Thyroglossal cyst (M)
Dermoid (M)
CONGENITAL
Branchial cyst (AT)
Thyroglossal cyst (M)
Dermoid (M)
NEOPLASTIC
Metastatic
Carcinoma
Thyroid
INFLAMMATORY ADENITIS
Bacterial (AT/PT)
Viral (AT/PT)
Granulomatous (PT/AT)
INFLAMMATORY ADENITIS
Viral (AT/PT)
Bacterial (AT/PT)
Granulomatous (PT/AT)
INFLAMMATORY ADENITIS
Viral (AT/PT)
Bacterial (AT/PT)
Granulomatous (PT/AT)
NEOPLASTIC
Lymphoma (AT/PT)
Thyroid Ca (M)
Sarcoma (AT/PT)
NEOPLASTIC
Lymphoma (AT/PT)
Thyroid Ca (M)
Salivary (AT)
Metastatic (AT/PT)
Vascular (AT/PT)
Neurogenic (AT)
CONGENITAL
Branchial cyst (AT)
Thyroglossal cyst (M)
AT anterior triangle
PT posterior triangle
M midline
younger group (0-15) -> Congenital (more common in this group) > inflammatory adenitis >
neoplastic(least to think of)
***middle age group (16-40) -> most present with congenital
***older age group (>40) -> (think of) neoplastic > inflammatory adenitis > congenital (least to
think of)
A. BENIGN VASCULAR LESIONS
1. HEMANGIOMAS
a. Classification of Vascular Anomalies
Tumors (proliferative)- grow by cellular or endothelial hyperplasia, regress or persists
Juvenile hemangioma
Rapidly involuting congenital hemangioma
Noninvoluting congenital hemangioma
Kaposiform hemangioendothelioma
Tufted angioma
endothelium,
local
defects
b. Description
overproliferation of vascular entities due to abnormal changes in angiogenesis
characterized histologically by high endothelial cell turnover
compared with vascular malformation which have normal endothelial cell turnover and
abnormal gross vascular anatomy
clinical "life cycle includes proliferative, plateau, and involution
30% are visible at birth, 70% become visible within one to four weeks after birth; majority are
visible a month after birth
of
visible lesion on the face or neck may signify presence of another internal hemangioma
or may be part of a syndromic complex
o
o
o
o
o
PHACES
Posterior fossa structural brain abnormalities
Hemangioma
Arterial Lesions
Cardiac abnormalities/Coarcatation
Eye abnormalities
over one-half of hemangiomas heal with an excellent cosmetic result without treatment
hemangiomas are proliferative lesions as compared to arteriovenous malformations which are
vessel malformations
Superficial
Deep
Compound
c. Clinical Presentations:
Cavernous
Capillary
Port-wine stain
Strawberry marks
Spider telangiectasia
Senile hemangiomas/ruby spots
d. Indications for treatment: (PAST E)
***usually just do watchful waiting and inform the parents/px that it will involute in time because chances
are, it will.
Lymphangioma circumscriptum
confined to superficial skin, forming small, vesicle-like lesions
Cavernous
tongue, cheek, floor of mouth, lips, nose
Cystic Hygroma
most common in the neck (posterior triangle behind the SCM) but may extend to
the head, face, axilla or mediastinum
Multicystic
tend to spread along vital structures and high incidence of recurrence
manifest as painless masses that may involve parotid glands, submandibular glands, or both
diagnosis is made based on clinical findings -> soft with straw-colored fluid upon aspiration
surgical excision with preservation of the vital structures is the treatment of choice
rarely cause symptoms of airway obstruction and excision is usually for cosmetic reasons
Lipoma
relatively uncommon in a major salivary gland
derived from fat cells
appear grossly as smooth, well-demarcated, bright-yellow masses
consists of mature adipose cells with uniform nuclei.
Tx: extraction of the affected tooth and its periapical soft tissue
Paradental Cyst
Due to inflammation of the gingiva overlying a partly erupted third molar.
Break Bati:
Odontogenic Keratocyst
rd
3 most common
scalloping on x-rays
great mimic (e.g. ameloblastoma, dentigerous cyst)
diagnosis is a histologic one
aggressive and can be difficult to remove
can grow quite rapidly, with frequent
recurrences
- 40% of OKCs appear in a dentigerous
relationship, 9% of dentigerous cysts are OKCs when the histology is examined
Residual Cyst
-
an odontogenic cyst that remains within the jaw after the removal of the tooth with which it was
associated
Gingival Cyst of the Newborn- Bohn's nodules
few or many, white to yellowish, round to oval, nodes in the maxillary and/or mandibular gingiva
and alveolar ridge of newborns (PAST-E)
cystic degeneration of epithelial rests of the dental lamina (rests of Serres).
majority of these cysts break by themselves, a few days after birth exuding the keratin.
In some babies they may remain for a period of several months, in such cases surgical opening
is indicated.
3. ODONTOGENIC TUMORS
Ameloblastoma
most common odontogenic tumor (PAST-E)
benign but locally invasive neoplasm
(acts like a malignant lesion) derived from
odontogenic epithelium
multicystic (86%), unicystic (13%) and peripheral (extraosseus 1%)
may arise from the lining of a dentigerous cyst but more often
arises independently of impacted teeth
progressive growth rate and may reach enormous proportions
symptoms may include a painless swelling, loose teeth, malocclusion, or nasal obstruction.
maxillary tumors frequently perforate into the antrum and may grow freely, with extension into the
nasal cavity, ethmoid sinuses, and skull base
they can exhibit cytologic features of malignancy with squamous differentiation (< 1%) -> malignant
degeneration
unilocular often confused with odontogenic cysts
radiograph shows multilocular radiolucency with a predilection for the posterior mandible, wellcircumscribed, soap-bubble appearance (PAST E)
Dx: biopsy
Tx: complete excision, including adequate zone of normal-appearing bone around the main tumor
mass; mandibular reconstruction
Calcifying Epithelial Odontogenic Tumor
Adenomatoid Odontogenic Tumor
Squamous Odontogenic Tumor
Calcifying Odontogenic Cyst
2. NEUROGENIC TUMORS
Neurilemoma (Schwannoma)
encapsulated neoplasms from Schwann cells
slow-growing tumor, present for several years
pain and neurologic symptoms are uncommon unless the tumor is
large or, by virtue of a deep-seated location, is impinging on neighboring structures.
waxing and waning of the tumor size may be noted due to fluctuations in the amount of cystic
change and high vascularity
common along lateral neck region
exact nerve of origin may be impossible to determine
CT Scan, MRI, biopsy
Surgical excision
Neurofibroma
affects all neural crest cells (schwann cells, melanocytes, endoneural fibroblasts genetically
inherited, autosomal dominant
usually arise from subcutaneous tissues(ill-defined and unencapsulated) but
may also occur deeper in head areas (circumscribed and encapsulated)
3. PARAGANGLIOMAS
arise from the glomus cells (chemoreceptors located along blood vessels that have a role in
regulating blood pressure and blood flow)
found in the abdomen (85%), thorax (12%), and head and neck (3%)
unlike paragangliomas of the abdomen,
head andneck paragangliomas
rarely secrete
catecholamines
most occur as single tumor
when occuring at multiple sites they are usually found as a part of a heritable syndrome such as
multiple endocrine neoplasia types II-A and II-B
MEN Type IIA
Medullary Ca
Pheochromocytoma
Parathyroid
3) Glomus tympanicum - from paraganglia along the tympanic branch of the glossopharyngeal
nerve, also known as Jacobsen's nerve, or the auricular branch of the vagus nerve, also known
as Arnold's nerve. It is often seen at the dome of the jugular bulb or submucosally at the cochlear
promontory. By definition it remains confined to the middle ear and mastoid air cells.
4) Glomus jugulare - within the jugular foramen from the jugular bulb, Jacobsen's nerve, or
Arnold's nerve. It may extend through bone into the mastoid air cells and middle ear with an
aggressive pattern of bone destruction.
Carotid Body Tumor/ Paraganglioma
most common head and neck paraganglioma
slow-growing, painless neck mass along the anterior edge of the SCM lateral to the tip of the
hyoid bone
may expand and cause bulging of the pharynx
may compress adjacent nerves to cause hoarseness, dysphagia, cord paralysis
Angiography, CT Scan
Surgical excision
4. LIPOMAS
5. RHABDOMYOMA
rare, benign tumor of striated muscles
important to differentiate from malignant rhabdomyosarcoma
Adult Rhabdomyoma
most common subtype, occuring at a mean age of approximately 50 years
predilection for head and neck region (larynx, pharynx, and the floor of the mouth)
circumscribed mass (usually less than 10 cm), coarse, with a brick-red colour
may be multinodular
Fetal Rhabdomyoma
slow growing mass, usually less than 5cm in size.
occurs primarily in the subcutaneous tissues of the head and neck region (common behind ear)
usually among infants usually less than 3 years of age
CT scan, MRI, section biopsy
Surgical excision
E. DEVELOPMENTAL NECK MASSES
1. DERMOID CYSTS (PAST E)
solitary, or occasionally multiple, hamartomatous tumor
containing structures derived
from ectoderm
covered by a thick dermis-like wall that contains multiple
sebaceous glands and almost
all skin adnexa
may contain substances such as nails and dental, cartilagelike, and bonelike structures
occur mostly on the face, neck, or scalp but can be intracranial, intraspinal, perispinal or within the
ovary or omentum
2. CERVICAL TERATOMAS
midline mass in an infant with airway obstruction
Ex. A dyspneic newborn w/ large midline neck mass (PAST E)
tumors containing tissue elements derived from all three germinal layers
usually discovered at birth, rarely presents after age of 1 year
encapsulated, partially cystic
sometimes referred to as thyroid teratoma since it is in the midline
symptoms develops over time due to progressive pressure, resulting in upper
airway obstruction
maternal hydramnios has been incriminated as a predisposing factor
Ultrasonography, CT scan
Surgical excision
Keratoacanthoma
develops over several months, assuming an elevated dome-shape
configuration with a central keratin plug
diagnosis is clinicopathologic
2. ADNEXAL TUMORS
Hair Follicle Tumors -> excise and send for histopathology
Trichoepithelioma
Trichofolliculoma
Pilomatrixom
Nevus Sebaceus
Sebaceous Adenoma
3. MELANOCYTIC TUMORS
Ephelis common freckle due to localized increase in melanin pigment
Lentigo nonspecific term for flat, macular hyperpigmented skin lesion, related to sun exposure
Melanocytic Nevus circumscribed new growth of skin of congenital origin
junctional at epidermal-dermal junction
intradermal confined at dermis
compound both junctional and intradermal are present
Premalignant Melanocytic Lesions irregular
Lentigo maligna flat, slow-growing, pigmented lesion
Atypical intraepidermal melanocytic proliferation more rapid growth
4. SEBACEOUS CYST
(EPIDERMAL CYST; KERATIN CYST; EPIDERMOID CYST)
closed sac found just under the skin, most often arising from swollen hair follicles
contains cheesy-looking skin secretions.
skin trauma can also induce a cyst to form
a sac of cells is created into which a protein called keratin is secreted
usually slow- growing, painless, freely movable lumps beneath the skin
occur in almost any part of head and neck
asymptomatic unless infected
management of infection with local heat, antibiotics and drainage
surgical excision with meticulous removal of all cyst remnants to prevent recurrence