RAJIV GANDHIUNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of the candidate & address / Dr. Divya jyothi.N
Permanent address: Samrudhi, Barebail,
Bejai post, Mangalore – 575004
Local address: Room No. 20,
Ladies hostel, Dr. B.R.Ambedkar Medical College campus, K.G.Halli
Bangalore – 45
Mobile No. :9900910316
Landline: 0824-6512450
Email: divyadevadiga
2 / Name of the institution / Dr. B.R.Ambedkar Medical College
K.G.Halli, Bangalore-45
3 / Course of study & subject / Post graduate in Otorhinolaryngology M.S(ENT)
4 / Date of admission to course / 22/06/2009
5 / Title of the topic
Clinicopathological study of neck masses in patients attending ENT outpatient department of Dr. B.R.Ambedkar medical college
6 / Brief resume of the intended work
6.1 Need for the study
6.2 Review of literature
6.3 Objectives of study / Annexure 1
Annexure 2
Annexure 3
7 / Methods & Materials / Annexure 4
8 / List of References / Annexure 5
9 / Signature of the Candidate
10 / Remarks of the Guide / Annexure 6
11 / Name and designation of (in block letters)
11.1 Guide
11.2 Signature
11.3 Co-Guide
11.4 Signature
11.5 Head of the department
11.6 Signature / Dr. KAILASH.N
PROFESSOR AND HOD DEPT. OF ENT .
Dr. Y A MANJUNATH
PROFESSOR OF DEPT.OF PATHOLOGY.
Dr. KAILASH. N
12 / 12.1 Signature of Principal

Annexure 1

6.1Need for the study

The present study is undertaken with a aim of finding the applicability of Fine Needle Aspiration Cytology(FNAC) in swellings of head and neck and its correlation of accuracy rated with concomitant histopathological examination. The study will further assess the common causes of neck swellings and also find the sensitivity of FNAC as a diagnostic tool.

Annexure 2

6.2 Review of literature:

Most of the benign conditions of the neck present as cervical masses. Half of all the neck masses seen in general hospitals are of thyroid origin. Other common neck masses are:

Congenital : lymphangioma, dermoid , thyroglossal cyst, branchial cyst, branchial fistulae, thymic cyst and haemangioma.

Acquired: ranulae, laryngocoele, pharyngeal pouches.

Infective : bacterial, viral, tubercular lymphadenopathy.

tumours of parapharyngael spaces.

Neurogenic tumours : paraganglioma, peripheral nerve tumours.(1)

Benign neck swellings may be nodal or cystic , lateral or central, neoplastic, inflammatory or congenital. Maisel suggests that 80% of non thyroid neck masses are neoplastic. This applies to masses over 2 cms in diameter in those over 35 years of age. This compares with 90% of the neck masses in children representing benign conditions of which 55% were congenital.(2)

In thyroid swelling thyroid nodule is more common in females and increases in frequency with age. While thyroid nodule is common , thyroid cancer is uncommon and presents as solitary thyroid nodule. FNAC is now the corner stone of investigation for many of these patients(3).

Metastatic neck swellings: one of the prognostic factor in head and neck cancer is the presence or absence , level and size of the metastatic neck disease. Many tumors within the head and neck will at some stage metastasize to the lymph nodes. Fine needle aspirations particularly useful when searching for unknown primary . The technique has a overall accuracy of 90%

In 1927 Forkner using 17-18 guage needle obtained tissue for biopsy.He could diagnose
22 out of 23 cases by this method.This included 10 hodgkins ,5 metastatic carcinomas,
2 sarcomas ,1 tuberculosis and 1 hyperplasia(5).
Bangsbo .C and Sorensen. H in (1971) published 41 casses of head and neck swellings FNAC showed specificity almost equal to that of conventional HPE(6).
Frable in 1976 performed 173 nodal aspirates this included 97 metastatic tumors and 16 lymphomas.The differentiation of sqaumous cell carcinoma was not always possible by FNAC(7).
.
Frable and Frable (1979 ) reported that the thin needle aspiration biopsy proved more valuable in management of head and neck tumors(7).
William .J. Frable and Mary Ann Frable (1979) reported FNAC of 567 swellings of head and neck region which included 91 thyroid,99 salivary gland,323 lymph node,69 bony swellings. The accuracy rate was 98% with 2.1%false negative reported. They concluded that success of FNAC depends on close cooperation of pathologists trained and interested in cytological diagnosis technique(7).
Jens Thomsen, Jen. Chr. Andreassen and Aangsbo.C(1973 )reported FNAC of 108 patients with head neck swellings. These included 47 lymph nodes, 32 parotid glands and 17 thyroid swellings. He found the diagnostic accuracy of FNACto be 93%(8).
Dejmek.a.et.al. (1990) found that FNAC from cystic lesion of head and neck region was in general not less accurate than FNAC diagnosis of solid lesions in that area(9).
Astiava Mondal and Roy Choudhary .B.K. (1992) reported FNAC of 1082 cases of head and neck tumours and their result are promising,their series included 680 tumours of lymph nodes,92 thyroid glands ,118 salivary glands,65 bone and cartilage and 27 other tumours. The diagnostic accuracy was 98.5% in lymph nodes,92.7% in thyroid gland,95.7% in salivary glands,95.4%in bone and cartilage and 88.8% in other tumours. The overall diagnostic accuracy was 96.2% with no false positive reports or complications(10).
According to C.J. Stewart, J.A.Duncan, M.Farquharsonand J.Richmond(1998) Pathology, FNAC accurately distinguished reactive lymphoid hyperplasia from malignant lymphoma in 97% of cases.However occasional wrong diagnosis occurred owing to sampling error or
misinterpretation. Ancillary studies can be applied to cytological samples and contribute to the diagnosis of most cases(11).
R. Gertner, M.D, L. Podoshin, M.D, M. Fradis, M.D, conducted a study where one hundred thirty eight fine needle aspirations (FNA) of neck masses were performed during a four - years period (1979 -1982). The pre - existing literature was reviewed. An accuracy rate of 85% in FNA of neck masses was found, and a 100% accuracy rate in cases of benign tumors of the neck and developmental cysts of the neck was found (12)
Annexure 3
6.3 Objectives of the study
  • To study the commonest cause of neck swellings in our set up.
  • To compare the accuracy of FNAC over open biopsy in assessment of cause of neck swellings.
  • To find the sensitivity of FNAC in diagnosis of neck masses
Annexure 4
7.1 Methods and Materials
  • The material consists of 100 patients with neck swellings coming to ENT outpatient department of DR.B.R.AMBEDKARMEDICALCOLLEGE hospital Bengaluru. The period of study will be two years.
  • Inclusion criteria: Patients with neck masses presenting to ENT outpatient department at Dr.B.R.AmbedkarMedicalCollege and Hospital.
  • Exclusion criteria: Suspected neck masses of vascular origin on clinical examination of neck mass.
  • Informed written consent taken from all patients.
  • According to proforma detailed history will be taken, through examination will be carried out and basic relevant investigations will be done in all the patients to arrive at a provisional diagnosis.
All the cases of neck swellings will be sent to department of pathology where fine needle aspiration biopsy will be done 21-23 gauge needle attached to the 10ml plastic disposable syringe-will be used with full aseptic precaution, needle will be inserted to desired depth in all cases and by pulling the piston out firmly a negative pressure is created in the syringe. The needle moved 2-3 times in different directions with piston pulled out to maintain negative pressure. The piston released to allow the pressure to equalize and the needle for 1-2 minutes. The aspirate will be injected on to the slide from the needle.
  • Air dried smears were stained with Haematoxylin and Eosin and MAY-GRUNWALD GIEMSA stain whereas 95% ethyl alcohol fixed smears were stained by Papanicoloau stain.
  • The cytological feature of all cases will be reviewed with the corresponding HP features after excision biopsy of the swelling except in cases where excision biopsy is contraindicated.
7.2 Does the study require any investigation or intervention to be done on patients or any other human or animal? If yes explain briefly.
  • Yes, study requires fine needle aspiration cytology and excision biopsy to be done after obtaining consent from the patient
7.3 Has ethical clearance been obtained from your institution?
  • Yes.
Annexure 5
8. List of references:
  1. Watkinson. J. C, Gagc. M. N. Wilson. J. A, Stell and Maran's head and neck surgery 4th solition (2000) Hodder Arnold publication, page 181
  2. Clarke Peter, Scott Brown's Otoloryngology head and neck surgery, 7th edition (2008), Hodder Arnold publication, page 1777
  3. Watkinson. J. C, Gagc. M. N. Wilson. J. A, Stell and Maran's head and neck surgery 4th edition (2000) Hodder Arnold publication, page 459
  4. Watkinson. John. C, Scott Brown's Otoloryngology head and neck surgery, 7th edition (2008), Hodder Arnold publication, page 2711, 2721
  5. Forkner. C. E (1927): Material from lymph node of man :Arch of internal medicine.
  6. Bangsbo. C and Soresen. H (1971): Aspiration Biopsy of head and neck swellings: Practica otolrhinolaryngologica 33:222.
  7. Frabte. W. J and Frable. M. A. S (1979): Thin needle aspiration biopsy - the diagnosis of head and neck tumours revised: Cancer 43:1541.
  8. Jen Thomson et al (1973): Fine needle aspiration biopsy of turnouts of head and neck: JLO, 87:1211.
  9. Dejmek. A, Lindholm. K (1990): Fine needle aspiration biopsy of cystic lesions of the head and neck excluding the thyroid. Acta cytol 34:443.
  10. Mondal. A et al (1989): Fine needle aspiration biopsy cytology in diagnosis of cervical Iymphadenopathy: Journal of Indian Medical Association, 887:108.
11. Stewart. C. J. Duncan. J. A, Farquharson. M and Richmond. J department of Pathology, Royal infirmary, Glasgow, UK(1998): Fine needle aspiration biopsy cytology in diagnosis of malignant lymphoma and reactive lymphoid hyperplasia, journal of clinical pathology, 51:197 - 203.
12. Gertner . R,Podosin . L,Fradis M(1984): Accuracy of fine needle aspiration biopsy in neck masses;Laryngoscope, volume94, issue10, page1370-1371.
Annexure 6
Remarks of the guide:
Neck swellings are the common conditions presenting to ENT out patient department. Due to the complex anatomical arrangement of the structures in the neck, the diagnosis of these swellings can be difficult and challenging, but early diagnosis proves helpful in the prognosis of the disease.