Australian Doctor Australian Doctor 7th September 2018

7 SEPTEMBER 2018 australiandoctor.com.au 22 HOW TO TREAT: NECK LUMPS IN ADULTS Figure 7. Laryngeal cancer arising from the left vocal fold. involved salivary gland to further characterise the lesion. 32,34 Presume adult patients with a per- sistent non-infectious neck lump that is present for more than two weeks have a malignant head and neck can- cer until proven otherwise. 33,1 Without delaying referral, arrange a CT of the head and neck with contrast followed by an ultrasound-guided fine needle biopsy of the neck lump. 34-36 Contrast helps to distinguish cystic from solid lesions and abnormal cervical lymph nodes, and may reveal small primary sites in the aerodigestive tract. Fine needle biopsies have an accuracy of more than 90% in diagnosing the aeti- ology of a neck mass. 1 Patients with a suspected or diag- nosed malignant cervical lymph node require urgent referral to a head and neck unit for outpatient assessment. A diagnostic laryngoscopy, bron- choscopy and oesophagoscopy (LBO) procedure may be arranged by the sur- geon to examine the upper aerodiges- tive tract under anaesthesia, define the extent of the primary tumour, look for synchronous primary tumours and to take biopsies. PET or integrated PET/CT imaging are used to investi- gate for possible distant metastases. In adults with suspected congen- ital or developmental masses, first arrange a CT of the neck with con- trast. This differs from the approach taken with paediatric patients. Given the lower likelihood of malignancy in these patients, order an ultra- sound first to avoid undue radiation exposure. If a thyroid nodule or goitre is evi- dent clinically, perform thyroid func- tion tests and an ultrasound of the thyroid and cervical lymph nodes. 35,37 Fine needle biopsy may be indicated depending on the ultrasound findings If lymphoma is suspected, perform an FBC and refer the patient for an ultrasound-guided core biopsy in con- sultation with a haematologist. Schwannomas are best imaged with an MRI of the neck. Paraganglio- mas are imaged with a combination of CT, MRI and angiography to diagnose and localise the tumour. MANAGEMENT REACTIVE lymphadenopathy gen- erally shows signs of improvement within a two-week period. If the neck lump is felt to have bacterial aetiol- ogy, prescribe a course of broad-spec- trum oral antibiotics and review the patient after two weeks. 1 Consider a Box 3. When to refer to a head and neck surgeon • Non-infectious neck lump present for more than two weeks • Clinical suspicion of a malignant neck lump • New diagnosis of neoplasm (benign or malignant) including head and neck SCC, and salivary gland or thyroid neoplasm malignant neoplasm if the lump per- sists or shows signs of growth during the review. Bacterial sialadenitis is most com- monly due to oral flora including S. aureus and can be managed with clin- damycin given its excellent penetra- tion into saliva. Warm compresses, chewing sialagogues such as lemon wedges, and rehydration measures are also essential. Treatment of viral siladenitis is supportive. Initial man- agement of sialolithiasis involves rehydration, warm compresses, sialo- gogues and analgesia. If conservative measures are unsuccessful at expel- ling the stone, surgical options include endoscopic stone retrieval, intra-oral excision over the stone (see figure 9) or complete gland removal. A patients diagnosed with head and neck SCCs and urgently referred to a multidisciplinary head and neck unit will be reviewed by a team that includes head and neck surgeons, plastic surgeons, radiation and med- ical oncologists, pathologists and speech pathologists. The management approach is guided by primary site and stage of disease, in addition to patient Figure 8. Anatomy of the neck. of disease. Adjuvant radiotherapy and chemotherapy are also incorporated into the treatment regimen depending on the stage of disease. Most benign and malignant sali- vary gland tumours are managed by surgical resection. Adjuvant radio- therapy may also be considered for advanced malignant salivary gland tumours or when clear margins are Consider a malignant neoplasm if a neck lump persists or shows signs of growth. factors, including their age, comorbid- ities and treatment goals. The National Comprehensive Cancer Network guidelines for head and neck cancer inform decision-making. For primary head and neck cancer with cervical lymph node metastases, the primary lesion is usually surgically removed and a cervical neck dissection is per- formed. Neck dissections involve removal of certain groups of cervical lymph nodes. The extensiveness of the neck dissection performed depends on primary site involved and the stage not obtained from surgery. Congenital neoplasms, including thyroglossal duct cysts, branchial cleft anomalies and dermoids, are excised by a head and neck surgeon, primar- ily to prevent recurrent infections and address disfigurement. Referral to a head and neck sur- geon is recommended after or while simultaneously arranging appropriate imaging and the fine needle biopsy. Indications for referral to a head and neck surgeon are listed in box 3. PAGE 24 Figure 9. A calculus excised from the submandibular duct.

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