Neck Mass

Neck Mass

Yonatan Avraham Demma

DIAGNOSIS

1. Patient history2. Physical examination3. Differential diagnosis4. Imaging studies5. Blood test

PATIENT HISTORY

The most important element in the evaluation of a neck mass is….

…the age of the patient .

Most pediatric neck masses are inflammatory or congenital and resolve spontaneously or after appropriate medical therapy.

In contrast, a neck mass in an adult over the age of 40 should be considered neoplastic in origin unless proven otherwise, particularly in the setting of tobacco or alcohol use.

PATIENT HISTORY

duration, growth pattern, and absence or presence of pain. change in voice, hoarseness, difficulty with swallowing, ear pain generalized complaints: fever, night sweats, and

weight loss. patient's social history: alcohol and drug use,

smoking, and recent travel.

PHYSICAL EXAMINATION

systematic investigation of all mucosal and submucosal areas of the head and neck.

mobility, consistency, and tenderness of the mass.

location of the neck mass is particularly important› Children: different branchial cyst› adult patients: virchov metastasis

ANATOMY

Differential diagnosis

Anterior triangle

bordered by anterior border of SCM, midline of neck, and mandible › muscular triangle

formed by midline, superior belly of omohyoid, and SCM

› carotid triangle formed by superior belly of omohyoid, SCM, and posterior belly of digastric

› submental triangle formed by anterior belly of digastric, hyoid, and midline

› submandibular triangle formed by mandible, posterior belly of digastric, and anterior belly of digastric

Posterior/Lateral triangle

bordered by posterior border of SCM, trapezius, and clavicle › supraclavicular

triangle formed by inferior belly of omohyoid, clavicle, and SCM

› occipital triangle- formed by inferior belly of omohyoid, trapezius, and SCM

ANTERIOR NECK

The structures that make up the anterior neck include

the larynx, trachea, esophagus, thyroid and parathyroid glands, carotid sheath, and suprahyoid and infrahyoid strap

muscles.

POSTERIOR/LATERAL NECKContains:

lymph node, the spinal accessory nerve, the cervical plexus. the brachial plexus subclavian vessels.

Differential Diagnosis

1. Congenital neck mass2. Inflammatory Neck mass:

› Infectious› Non infectious

3. Neoplastic Disorder

CONGENITAL NECK MASSES

1. BRANCHIAL CLEFT CYSTS2. THYROGLOSSAL DUCT CYSTS3. LARYNGOCELES4. PLUNGING RANULAS5. LYMPHANGIOMAS6. HEMANGIOMAS7. TERATOMAS - DERMOID CYSTS8. THYMIC CYSTS9. STERNOCLEIDOMASTOID TUMORS OF INFANCY

1 .BRANCHIAL CLEFT CYSTS failure of the

pharyngobranchial ducts to obliterate during fetal development.

most frequently present in late childhood or early adulthood when the cysts become infected usually after an upper respiratory tract infection.

tender, inflammatory mass located at the anterior border of the sternocleidomastoid muscle.

Classification

three categories: first, less than 1% second, the most common and third branchial cleft anomalies.

Treatment

1. initial control of the infection2. surgical excision of the cyst and tract.

incision and drainage procedures should be avoided

2 .THYROGLOSSAL DUCT CYSTS

one-third of all congenital neck masses. midline masses of the anterior neck . may be asymptomatic and appear only

when they become infected. Thyroglossal duct cysts that occur off the

midline may be difficult to differentiate from branchial cleft cysts.

pathognomonic sign on physical examination is vertical motion of the mass with swallowing and tongue protrusion, demonstrating the intimate relation to the hyoid bone.

The Sistrunk operation excised with a cuff

of tissue, including the center portion of the hyoid bone.

care is taken not to injure the hypoglossal nerves;

thyroid carcinomas can be present in a small percentage of thyroglossal duct cysts

3 .LARYNGOCELES

abnormal dilation or herniation of the saccule of the larynx.

Laryngopyocele is a Secondary infection of a laryngocele.

present with hoarseness, cough, dyspnea, dysphagia, a foreign body sensation.

Dx: Laryngoscopy, CT. If symptomatic, Tx:

› laryngoscopic decompression for small lesions, › surgical excision through an external approach for larger

lesions,

Laryngocele

PLUNGING RANULAS

mucoceles of the floor of mouth usually present as slow-growing,

painless, submental masses. arise from the sublingual gland and are

defined as plunging when they extend through the mylohyoid muscle into the neck.

Tx: excision.

LYMPHANGIOMAS

congenital malformations of the lymphatic channels.

They arise owing to failure of the lymph spaces to connect to the remaining lymphatic system.

The mass is usually soft, doughy, smooth, nontender, and compressible.

can be transilluminated. CT scanning and MRI are important studies both

to delineate the extent of the disease

Tx: Surgical Debulking because of the infiltrative nature

HEMANGIOMAS

malformations of vascular tissue. usually present in the first few months of life,

grow rapidly during the first year, and then begin to slowly involute at 18–24 months of age.

In 90% involution occurs without the need for any therapy.

present as a red or bluish soft mass that is compressible and increases in size with straining or crying.

Bruits may sometimes be auscultated over the lesion. Dx: CT scans, MRI. In the following symptoms: airway compromise, skin

ulceration, dysphagia, thrombocytopenia, cardiac failureSystemic corticosteroids or surgical laser excision may be warranted in such cases.

TERATOMAS - DERMOID CYST

approximately 3.5% of all teratomas.

Their origin is from pluripotential cells, contain elements from all three germ layers.

Usually present as midline, nontender, mobile neck masses and are most commonly noted at birth or within the first year of life.

There is a 20% associated incidence of maternal polyhydramnios.

can cause respiratory compromise or dysphagia secondary to compression.

Dx: CT, MRI.

Tx: Surgical excision.

THYMIC CYSTS

The third branchial pouch gives rise to the thymus during the 6th week of fetal life, elongates in the pharynx, and then descends into the mediastinum.

Thymic cysts arise when there is implantation of this thymic tissue along this descent.

present as slow-growing, asymptomatic masses that may be painful if infected.

On rare occasions, they grow rapidly and cause dyspnea or dysphagia.

CT scanning and MRI are useful in the differential diagnosis.

definitive diagnosis is made histologically by the presence of Hassall corpuscles.

Tx: surgical excision.

STERNOCLEIDOMASTOID TUMORS OF INFANCY

characterized histologically by dense fibrous tissue and the absence of normal striated muscle.

intimately related to congenital torticollis. typically present as firm, painless, discrete

masses within the sternocleidomastoid muscle; slowly increase in size for 2–3 months and then

regress for 4–8 months. 80% resolve spontaneously and do not need

any intervention other than physical therapy to prevent restrictive torticollis.

Surgical resection is reserved for persistent cases.

INFLAMMATORY NECK MASSES

Infectious inflammatory disorder: Viral (reactive, HIV) Bacterial (suppurative, toxoplasmosis,

tularemia, brucellosis) Granulomatous (cat-scratch disease,

actinomycosis, atypical mycobacteria, tuberculosis, atypical tuberculosis, sarcoidosis)

Non infectious inflamatory disorder: Sinus histiocytosis – Roni-Dorfman disease Kawasaki disease Castleman disease

VIRAL LYMPHADENOPATHY

REACTIVE VIRAL LYMPHADENOPATHY

HIV-ASSOCIATED INFLAMMATORY DISORDERS

REACTIVE VIRAL LYMPHADENOPATHY

the most common cause of cervical adenopathy in children.

usually associated with symptoms of an underlying upper respiratory tract infection.

The most common viral agents include adenovirus, rhinovirus, and enterovirus.

tend to regress in 1–2 weeks.

Management

Usually observation a neck mass larger than 1 cm should

be considered abnormal and warrant further investigation if it remains for more than 4–6 weeks or increases in size.

If persists, biopsies can be taken to search for other causes.

Mononucleosis

EBV can also present with lymphadenopathy

usually accompanied by the enlargement of other lymphoid tissues such as the adenoids or tonsils.

symptoms of fever and pharyngitis. 4–6 weeks. Tx: limited to supportive

management.

HIV-ASSOCIATED INFLAMMATORY DISORDERS

Cervical Adenopathy or Persistent Generalized Lymphadenopathy

present in 12–45% of patients with human immunodeficiency virus (HIV).

other infectious or neoplastic etiologies must be ruled out

Tx: HIV Tx

BACTERIAL LYMPHADENOPATHY

1.Suppurative Lymphadenopathy

2.Toxoplasmosis3.Tularemia4.Brucellosis

Suppurative Lymphadenopathy most frequently caused by Staphylococcus

aureus and group A B-Streptococcus. usually develop in the submandibular

region often accompanied by sore throat, skin

lesions, and upper respiratory tract infection.

Empirical antibiotic therapy against anaerobic and gram-positive organisms is recommended as the first line of management.

If this fails, either FNA or incision and drainage may be indicated.

Toxoplasmosis

caused by Toxoplasma gondii contracted through the consumption of

poorly cooked meat or the ingestion of oocytes excreted in cat feces.

present with fever, malaise, sore throat, and myalgias.

Dx: serologic testing. Tx: ABx ex: sulfonamides

(resprim).

Tularemia

caused by Francisella tularensis transmitted by rabbits, ticks, or

contaminated water. present with tonsillitis and painful

adenopathy with systemic symptoms of fever, chills, headache, and fatigue.

Dx: Serology and Bc. Tx: Streptomycin is the antibiotic of

choice.

Brucellosis

Cause by Brucella. most commonly transmitted to

children by the ingestion of unpasteurized milk.

present with total body lymphadenopathy, fever, fatigue, and malaise.

Dx: Serology and BC. Tx: Abx : trimethoprim–

sulfamethoxazole or tetracycline

GRANULOMATOUS DISEASES

cat-scratch disease, actinomycosis, atypical mycobacteria, tuberculosis, atypical tuberculosis, sarcoidosis.

Cat-Scratch Disease

Bartonella henselae. history of contact with cats can be

elicited in 90% of cases. more commonly seen in patients

younger than 20 years. tender lymphadenopathy, fever,

and malaise. lymphadenopathy typically

preauricular and submandibular. Dx: serologic testing. generally benign and self-limited.

Actinomycosis

gram-positive bacillus. 50% to 96% of cases of actinomycosis

affect the head and neck regions. painless, fluctuant, neck mass in

the submandibular regions. DX: histologically by the presence of

granulomas with sulfur granules. TX: Penicillin

Atypical Mycobacteria

typically presents in the pediatric population

unilateral neck mass located in the anterior triangle of the neck or parotid region.

brawny skin, induration, and pain.

Dx: culture and skin testing. Tx: Surgical excision offers definitive

treatment, although incision and curettage along with antibiotic therapy constitute an alternative management strategy.

Tuberculosis

more commonly in adults than in children.

Mycobacterium Tuberculosis The presenting lymphadenopathy

tends to be more diffuse and bilateral in contrast to atypical mycobacteria.

Tuberculin skin tests are strongly positive.

Cervical tuberculosis is also known as scrofula

Tx: antituberculous medications.

Sarcoidosis

presents most commonly in the second decade of life

lymph node enlargement, fatigue, and weight loss.

Chest radiography shows hilar adenopathy.

An elevated angiotensin-converting enzyme (ACE) level is seen in 60–90% of patients with sarcoidosis.

Dx: histologically by the presence of noncaseating granulomas.

TX: Corticosteroids.

FUNGAL INFECTIONS

Immunocompromised patients.

Most common organisms Candida, Histoplasma, and Aspergillus.

Dx: Serology and fungal cultures.

Tx: Aggressive, systemic antifungal therapy with agents such as amphotericinB

NONINFECTIOUS INFLAMMATORY DISORDERS

Sinus histiocytosis – Rosai-Dorfman disease

Kawasaki disease Castleman disease

ROSAI–DORFMAN DISEASE SINUS HISTIOCYTOSIS

typically presents in children with massive nontender cervical lymphadenopathy, fever, and skin nodules.

characterized by benign, self-limited lymphadenopathy.

Biopsy shows classically dilated sinuses, plasma cells, and the proliferation of histiocytes.

KAWASAKI DISEASE

acute multisystem vasculitis in children. present with:

› acute, nonpurulent cervical lymphadenopathy;

› erythema, edema, and desquamation of the hands and feet;

› polymorphous exanthem;› conjunctival injection; and erythema of the lips

and oral cavity. Dx: made by clinical judgment. Early identification and treatment with

aspirin and globulin are imperative in avoiding serious cardiac complications.

CASTLEMAN DISEASE

a rare, benign lymphoepithelial disease potential development of Kaposi sarcoma

and lymphoma. This disease affects both sexes equally

and can occur at any age. This disease occurs most commonly in

thoracic lymph nodes (70%). Dx: tissue biopsy. Tx: Isolated - surgical resection with

excellent prognosis. Multicentric - chemotherapy

NEOPLASTIC DISORDERS

1. METASTATIC LYMPH NODE2. THYROID MASSES3. LYMPHOMAS4. SALIVARY NEOPLASMS5. PARAGANGLIOMAS6. LIPOMAS7. SOLITARY FIBROUS TUMOR

METASTATIC SCC

tend to present as asymptomatic lesions that progress slowly

firm to palpation. The associated symptoms are related to the

primary site: odynophagia, dysphagia, dysphonia, otalgia, and weight loss.

The most common metastatic lesion to the neck is squamous cell carcinoma.

Dx: FNA biopsy. More reccurence with excisionnal Bx

CT and MRI, may be helpful in the search for the primary tumor.

If the initial examination and imaging fail, a direct endoscopic examination.

Knowing the location of the node assists in guiding the surgeon to suspicious areas.› posterior triangle: nasopharyngeal lesion, › jugulodigastric nodes: tonsils, base of tongue,

or supraglottic larynx.› supraclavicular area: digestive tract,

tracheobronchial tree, breast, genitourinary tract, and thyroid gland.

THYROID MASSES

A primary thyroid tumor manifests in the anterior compartment of the neck.A thyroid mass in a patient with hoarseness and a history of neck irradiation should be considered malignant.Dx: Ultrasound, thyroid scans, and thyroid function tests.

Dx: FNA.The treatment is based on histologic findings.

LYMPHOMAS

can occur in all age groups but more common in children and young adults.

In Hodgkin disease, up to 80% will have at least one neck mass.

presents with fever, chills, and diffuse lymphadenopathy.

Dx: FNA suggestive for lymphoma. Open biopsy may be necessary to obtain sufficient tissue for histopathologic classification.

Staging workup that includes CT scanning of the head, neck, chest, and abdomen.

SALIVARY NEOPLASMS

Most parotid lesions are found to be benign. Submandibular gland tumors have an

increased incidence of malignant pathology. Benign salivary lesions typically present as

asymptomatic masses. Symptoms such as pain, cranial nerve

involvement, rapid growth, or overlying skin involvement are highly suggestive of malignant growths.

Dx: CT scanning, MRI, nuclear scans, and sialography.

FNA is the diagnostic test of choice. Tx: surgery

PARAGANGLIOMAS

arise from extra-adrenal paraganglia. Carotid body tumors and glomus tumors are

paragangliomas that present as neck masses in the upper jugulodigastric region in close proximity to the carotid bifurcation.

They are pulsatile, and bruits can usually be heard on auscultation.

are mobile from side to side but not up and down. 10% have a family history, 10% present with multiple

paragangliomas, 10% of all paragangliomas are malignant.

Dx: The gold standard was angiography in the past, but today MRA.Tx: Surgical excision, Radiation for non resectable case, preoperative embolization may aid in the surgical resection.

LIPOMAS

most frequently in patients over 35 years of age.

can occur in various neck locations. Asymptomatic Dx: CT, MRI. Tx: surgical excision if symptomatic.

DD: Liposarcoma: similar imaging appearance but more progressive and locally infiltrative course.

Biopsy can be considered in such cases.

SOLITARY FIBROUS TUMOR

spindle cell neoplasms of mesenchymal origin.

Most solitary fibrous tumors are located in the thorax.

An estimated 5–20% of thoracic solitary fibrous tumors have been reported as malignant, but malignant extrathoracic tumors are rare.

In the head and neck, the oral cavity is the most common site, but there have been case reports involving all head and neck sites.

present as asymptomatic slow-growing masses.

Tx: local resection.

Imaging Studies

CT MRI.

› differentiate solid, cystic, and vascular masses;› localize a mass in relation to the vital structures of the neck;› identify a potential head and neck source for the neck mass

Ultrasonography› distinguishing solid from cystic masses

Chest X-rays› if there is a high index of suspicion for granulomatous

diseases such as sarcoidosis or tuberculosis.A chest film is also able to detect a metastasis from a head and neck cancer or a primary malignant neoplasm within the lungs.

Positron emission tomography

Serologic Testing

looking for systemic diseases: antinuclear antibody in Sjogren

syndrome, which can present with parotid enlargement and lymphadenopathy.

tuberculosis, atypical mycobacteria, mononucleosis, toxoplasmosis, cat-scratch disease.

Fine-Needle Aspiration Biopsy

use of a 23- or 25-gauge needle.

can differentiate a cystic mass from an inflammatory mass, malignant tissue from benign tissue, lymphoma from carcinoma.

PCR for EBV, HPV in suspicious Scc.