- Challenging in determining etiology
- Occurs in all age groups
- Variety of causes-congenital, inflammatory, benign neoplastic, malignant neoplastic, & other conditions
- Goal (basic evaluation of neck masses and overview of some of the more common neck masses)
MEDICAL HISTORY AND PHYSICAL EXAMINATION
- Crucial in evaluating a neck mass
- Patient age, duration and rate of growth of the mass, social history, presence or absence of systemic symptoms
- Asymptomatic neck mass among adults older than 40 years should be considered malignant until proven otherwise
- Adults, 80% of nonthyroid, nonsalivary glands are neoplastic, and 80% of neoplastic masses are malignant
- Children, 90% of neck masses are benign
- Slow growing masses tend to be benign
- Suddenly appearing masses or rapidly growing tend to be inflammatory or neoplastic
- Risk factors: smoking, ETOH, drug use, HIV status, living environment, occupation, travel history and family history of cancer
- Neck masses accompanied by fevers, chills, night sweats, myalgia may represent a local manifestation of systemic disease such as: a lymphoproliferative disorder, or may suggest an inflammatory disorder.
- A complete physical exam is essential to determine the primary site. Neck masses usually represent spread from the primary site
- Otolaryngologic exam involves visualization of all mucosal surfaces of nose, nasopharynx, oral cavity, oral pharynx, and larynx
- Tongue base & oral cavity must be palpated
- Examine the skin of scalp, head, face, and neck to rule out cutaneous lesions such as; melanoma, squamous cell carcinoma, basal cell carcinoma as the causes of the neck mass
Location of Mass
- Inflammatory or neoplastic masses usually follow the drainage pattern for the lymphatic vessel of the neck (32:1)
- mass location may give clue to the site of a primary infection or tumor
- Posterior cervical chain lymph node drains nasopharynx and sinuses. Anterior cervical chain lymph nodes drain the upper aerodigestive track oral cavity to esophagus running from superior to inferior. Supraclavicular nodes may drain the lower areas of the larynx and hypopharynx. However, may represent the spread of tumor from distant areas, such as lung, breast, GI tract and kidney. Midline neck masses are most frequently thyroid or congenital in origin.
- Tender masses especially if associated with systemic signs of infection usually are inflammatory.
- Tenderness however may be absent with atypical mycobacterial adenitis despite overlying skin edema
- Tumor masses may be tender with central necrosis or secondary infection
- Benign or inflammatory masses usually are mobile.
- Fixed masses are more likely to represent malignant process
- Soft masses often represent congenital cystic lesion or other benign lesions (lipoma, lymphoma, hemangioma, branchial cleft cyst, etc.)
- Hard masses are more likely to be malignant. However, toxoplasmosis may cause extremely hard nodes.
- Fixation of the overlying skin to the mass indicates a malignant infiltration process
- Punctum, dimple, or sinus tract may occur with branchial anomalies or dermoid cyst.
Ancillary Test- may provide important diagnostic clues
- CBC: infection (leukocytosis and shift) or signs hematological malignant disease (lymphoma or leukemia)
- ESR: may be elevated by systemic infection or tumor but is nonspecific
- Monospot: are diagnosis for infectious mononucleosis (EBV)
- CXR: may help identify a granulomous disease such as a sarcoid or TB that represents itself with a neck mass. May show evidence of pulmonary metastases from a malignant tumor of the head and neck
- Fine Needle Aspiration (FNA): valuable & diagnostic tool in patients with a neck mass in whom metastatic carcinoma is suspected.
FNA specificity ranges from 94%-100%
FNA sensitivity ranges from 92%-100%
Nearly 100% in diagnosis epithelial malignancies
- PPD: aids in the diagnosis of TB, sputum smear and culture for AFB may show TB or other mycobacterium
- Special serologic test: angiotensin converting enzyme levels for suspected sarcoid
- VDRL and FTA-ABS: for syphilis
- Thyroid scan: thyroid masses, especially in patients with history of neck irradiation, family history of thyroid disease
- Sonograms: help differentiate cystic and solid masses
- Panendoscopy: the evaluation of aero digestive tract to determine the site of the primary malignant neoplastic (direct layngoscopy brochnoscopy, esophagoscopy)
- CT of neck with IV contrast enhancement from the skull base to the clavicle. Helpful in determining the nature of a mass (solid, cystic, necrotic) origin and extent of the mass. It may identify bone invasion and sub-mucosal lesion not seen on physical exam or endoscopy.
- MRI: multiplanar, better resolution of soft tissue structures than CT. No radiation exposure, however inferior to CT in assessing bone involvement and can not be used if patients contain metal at vital sites.
Normal Neck Structures
mastoid tip, angle of the mandible, greater cornu of the hyoid bone, thyroid cartilage, styloid process of C2 and submandibular gland. Prominence of one of these structures should not be mistaken for an abnormal mass.
Congenital Neck Masses
- More frequently occur among children but may occur in adults. Suspected when a mass has been present from birth or has slowly enlarged over a period of months. Most are solitary and rarely tender unless associated with infection.
- They may fluctuate in size and appear as a inflammatory mass located in the same place each time.
Branchial Cleft Remnants
- They occur in the upper neck along the anterior border of the sternocleidomastoid muscle. Occasionally in the pre-auricular, infra-auricular or post-auricular regions.
- They may exist as pure cysts or as cysts associated with incomplete sinus or complete fistulas tract.
- They are initially related to the adjacent neuro-vascular structures derived from the arch.
- They may fluctuate in size during recurrent URI and may become infected.
- 85% of the cases arise from the second branchial cleft apparatus
- Treatments consist of complete surgical excision, should be done early because they become chronically infected.
- Branchiogenic carcinoma is a rare cancer found within the branchial cleft remnant
Thyroglossal Duct Cyst
- Surgical removal is the treatment of choice includes the body of the hyoid bone and a portion of the base of the tongue to excise the entire tract.
- Thyroid scan or sonogram should be performed to confirm the presence of normal thyroid gland before the operation.
- congenital lymphatic malformation that commonly occurs in the neck
- usually present at birth or appear within six months to 1 year afterwards
- they are soft doughy and comprehensive
- surgical excision is the treatment, the natural history is progressive growth and recurrent infection
- they are usually present at birth or within the first years of life
- red or bluish mass that increases in size with straining or crying and blanch with pressure
- other hemangiomas may present of other body parts
- the natural history is rapid growth with slower spontaneous regression requiring no intervention
- occasionally hemangiomas cause serious cosmetic or functional problems (airway compromise, eye, consumptive coagulopathy) necessitating treatment
- various therapeutic modalities (surgical, resection, argon laser, steroids, sclerosing agents, interferon alfa-2)
Dermoid cyst and Teratoma
- May be cystic or solid most frequently found in the midline and the submental region
- treatment is surgical excision
- Teratoma of the neck commonly present in newborns in acute respiratory distress. The masses are made of mature elements of ectoderm, mesoderm, endoderm. Emergent surgical excision required.
Sebaceous Cyst and Epidermoid Inclusion Cyst
- may appear in any part of the neck, usually asymptomatic unless they become infected
Fibromatosis Colli (psuedo tumor of infancy)
- also known at SCM tumor of infancy, congential torticollis and SCM fibroma
- affect 0.4% of all newborns
- swelling within the SCM when head turned away from the affected side
- treatment is passive cervical stretching, most recovery completely without long term sequel
- recent onset of a mass that is tender erythematous and warm suggest an inflammatory process, however neoplastic and congenital masses may undergo degenerative inflammatory reactions with similar findings.
- several small tender lymph nodes in a child’s neck most often represents lymphademitis associated with URI, usually viral in origin
- bacterial causes such as strep tonsillitis, pharyngitis, sinusitus, ear infections, skin infections; should be treated with appropriate antibiotics.
- lymph nodes may absess that necessitate needle aspiration or I&D
- caused by EBV
- presents with acute exuded tonsillitis, pharyngitis, fever, malaise, bilateral matted rubbery posterior cervical adenopathy
- serological test: monospot heterophile antibody
- treatment is supportive
- CMV, toxoplasmosis, leptospirosis, burcellosis, pateurellosis may produce mono like symptoms with diffuse cervical lymphadenitis
- screening test for these infections should be performed only after more common disorders have been ruled out
Mycobacterial Cervical Adenitis
- Caused by TB and atypical mycobacterium
- cervical adenitis in TB involves multiple, bilateral, matted nodes in the lower neck and supraclavicular region
- atypical mycobacterial adenitis usually involves unilateral nodes in the upper neck. PPD is negative or weakly positive (10mm wheel) more common cause of cervical adenopathy in children than TB
- treatment of mycobacterial cervical adenitis consist of multi-drug therapy, surgical excision is reserved for abscess nodes of node not responsive to medical treatment
- excision of involved lymph nodes is the choice of therapy for atypical mycobacterial; they are less responsive to standard anti TB drugs
Sarcoidiosis (chronic granulomatous disease of unknown origin)
- African-American population most common
- manifestations fever, weight loss, rubbery cervical adenopathy and hilar adenopathy
- cortico steroids for patients with symptoms
- frequently have asymptomatic cervical adenopathy
- nodes are usually multiple, small shoddy in texture and may be matted
- excisional biopsy should be performed if lymphoma is suspected
- lipoma and fibroma usually appear as asymptomatic masses in the subcutaneous tissue
- simple excision for sure
- subcutaneous and epidermoid inclusion cyst are benign masses and may appear in any part of the neck asyptomatic unless they become infected, treatment is local excision
- may occur at any age
- children is the most common malignant tumor of the neck, account for more than 50% of the cases
- generalized adenopathy, constitutional symptoms (fever, weight loss, night sweats, chills, hepatomegaly, large hilar lymph nodes on CXR) supports the diagnosis
- treatment and chemotherapy, radiation therapy or combined treatment
- most common solid tumor of the head and neck found in children 1 to 5 years old
- may arise from the orbit, nasophaynx, pharynx, neck or ear
- cranial nerve deficits suggest involvement of the skull base
- multimodiality therapy (surgery, radiation, chemotherapy)
- Neurilema (schwannoma), neurofibroma, neurofibrosarcoma, neuroblastoma,
- schwannoma and neurofibroma may arise from sensomotor or sympathetic nerves in the neck
- schwannoma may affect CN IX,X,XI,XII or SNS
- most common cause of malignant neoplastic neck masses among adults
- rarely occurs among children with the exception of metastatic disease from a primary nasopharyngeal tumor
- the primary tumor with metastatic SCCA to the neck most often originates in the upper aerodigestive tract
- complete history & physical exam often reveals the site of primary tumor
- FNA of neck mass to confirm diagnosis of SCCA
- MRI and CT are extremely helpful in determining the mass and its relation to the surrounding vital structures
- Endoscopy of the upper aerodigestive tract with biopsies of suspect regions
- Surgical resection of primary tumor, neck dissection XRT, chemo or any combination may be needed
- History & Physical Exam-Important
- age, risk factors, duration, size/change in size
- location, firmness, mobility
- Appropriate diagnostic studies
- Differential diagnosis
- inflammatory, congenital, benign, neoplastic malignant neoplastic
1. What is a midline mass that elevates with tongue protrusion? Thryroglossal duct cyst
2. What type of bacteria produces Scrofula? Mycobacterium
3. Which is the most common branchial cleft cyst? 2nd arch
4. 60 yr. old male with a 5 cm neck mass hx of smoking, ETOH use, what would be the most likely diagnosis? Squamous cell Carcinoma
5. 10 yr. old child bilateral, shoddy adenopathy with URI. What it the most likely diagnosis? cervical adenitis (viral, bacterial)
6. 16 yr. old male with adenopathy and positive mono spot. What is the most likely diagnosis? Mononucleosis.