Neck Masses

Presented by Wan Nabilah

Supervised by Prof. Mohammad Khammash

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Anatomy of the neck (central & lateral)

Central neck includes midline structures such as the hyoid bone, thyroid and cricoid cartilages, the thyroid isthmus and the trachea

The sternocleidomastoid muscle divides the lateral neck into 2 major triangles:

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Anatomical regions of the neck

Lymph nodes of the head and neck

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History Physical Examination +/- Investigations

Approach to neck masses

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Age 

Mass growth pattern : duration,size, painful, skin changes, other masses

Head & neck symptoms

Review of systems• Fever, night sweats, weight loss, pallor, itching Lymphoma• Loss of appetite & weight, pulmonary, alimentary or skeletal symptoms

Neoplasm• High spiking fever, rigors, general malaise Acute infection

Past medical history : past malignancy, previous infection Family history : malignancy

Social history : smoking, alcohol, illicit drug use, previous irradiotion, occupational exposures, travel history)

History

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Physical Examination Inspection• Mass localization, Site

Neck masses: site

Midline

ThyroidDermoid cystThymic cyst

Lymphadenopathy

Lateral

Anterior triangle

LymphadenopathyBranchial  cyst

Posterior triangle

LymphadenopathyCystic hygroma

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• Shape, color• Relation to muscles (muscle contraction)• Relation to trachea (swallowing)• Relation to hyoid bone (tongue is protrusion)

Palpation: temperature, tenderness, mobility, fluctuation, edge, size, surface, consistency, pulsation.

Percussion for retrosternal goiter

Auscultation for bruits

Complete Head & Neck Examination (Mouth, ENT, skin, LNs, thyroid, cranial nerves…)

Systemic examination (RS & GI)

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Laboratory studies• When the history or physical examination does not suggest

transient reactive lymphadenopathy as the cause of a neck mass.

• Persistence of a newly discovered neck mass beyond three weeks.

• CBC, TFT• ESR, blood culture• EBV, CMV serology• Tuberculin skin test

…

Investigations

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Imaging studies• Chest X Ray• Contrast CT scan of the neck• US• MRI or PET/CT scanning for follow-up.

Diagnostic studies:• FNAB (inflammatory vs neoplastic masses)o Biopsy should never be used before excluding lesions such as

a carotid body tumor, an aneurysm or a pharyngeal pouch.

• Core needle biopsy• Excisional or incisional biopsy

Investigations

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Neck Mass

Congenital

Midline :1- Thyroglossal Cyst

2- Dermoid Cyst

Lateral : 1- Branchial Cyst2- Muscular Mass3- Cystic Vascular4- Cystic Hygroma

Acquired

1- Lymphadenopathy2- Infectious3- Neoplastic

4- Primary Reticulosis5- Sebaceous Cyst

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Cervical lymphadenopathy

Reactive viral lymphadenopathy

Tuberculous lymphadenitis

Metastatic tumors

Primary neoplasms

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Enlargement of the cervical lymph glands is the commonest cause of a swelling in the neck.

The four main causes of cervical lymph gland enlargement are:

1. Infection: non-specific tonsillitis, TB, glandular fever, toxoplasmosis, cat scratch disease.

2. Metastatic tumor: from the head, neck, chest and abdomen.

3. Primary tumor: lymphoma, lymphosarcoma, Reticulosarcoma.

4. Sarcoidosis.

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This child presented with a swelling in his neck post upper respiratory tract infection, it was firm, tender and mobile. Diagnosis?

Reactive viral lymphadenopathy (tonsillitis)

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Reactive viral lymphadenopathy

• The upper deep cervical glands are most often affected.

• The common presenting symptom is a painful lump just below the angle of the jaw.

• Usually associated with tonsillitis in young children.• Mobile

Treatment is usually by treating the underlying cause.

(Antibiotics…)

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Tuberculous lymphadenitis• Upper deep cervical gland, usually with no generalized

infection.• Children, young adults and elderly.• Gradual onset of a lump in the neck +/- pain (pain if it

grows rapidly and necrose).• Usually not tender with normal color.

• In early stages the glands are firm, discrete & between 1-2 cm in diameter.

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Tuberculous abscess:• The swelling increases in size, becomes more painful, with

discoloration of the overlying skin and normal temperature (cold abscess).

• There may be tachycardia, fever, anorexia and general malaise.

• As caseation increases and the glands necrose it forms indistinct, firm mass (matted together).

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Treatment:

• A full course of antituberculous chemotherapy is given.• Small nodules are observed & should be excised if they enlarge.

• Tuberculous abscess: drainage (aspiration or incision) + continuation of medical therapy.

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Tuberculous lymphadenitis A chronic tuberculous sinus that has become secondarily infected

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Metastatic tumors• Metastatic deposits of

cancer cells are the commonest cause of cervical lymphadenopathy in adults.

• Most common in ages between 55-65 years.

• More common in men.

• The patient usually presents with painless hard, enlarged lymph glands in the neck.

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The site of the affected glands gives a crude indication of the site of the primary lesion:

• Lesions above the hyoid bone drain into the upper deep cervical glands.

• The larynx & thyroid drain into the middle & lower cervical glands.

• An enlarged supraclavicular lymph gland commonly indicates intraabdominal or thoracic disease. (ex. Virchow’s gland/ Troisier's sign).

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• Primary cancers in H&N do not cause anorexia and weight loss, they may have local symptoms (sore tongue, hoarse voice..)

• If the primary tumor is in the chest (cough or hemoptysis), or the abdomen (dyspepsia or abdominal pain) + general symptoms of anorexia and weight loss.

• Normal color, may be pale or blotchy red (if large enough to stretches or infiltrates the skin).

• Not tender, variable sizes.• Stony hard.• Tethered to the surrounding structures, so they can

usually be moved in transverse direction but not vertically.

FNAB is the STANDARD of diagnosis for neck masses If you suspect malignancy (90% true diagnosis).

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• The most common is the malignant lymphoma (Hodgkin’s & Non-Hodgkin’s)

• Two peak; 15-35 years and above 50 years.• Males are more often affected.• Painless, slowly growing lump in the neck• Usually in the posterior triangle.• Solid & rubbery in consistence, not tender, usually

associated with pruritus.• General symptoms (malaise, weight loss, pallor, itching,

fever and rigors)

Treated by radiotherapy and chemotherapy.

Primary neoplasms of the lymph glands

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Lymphoma in the posterior triangle, in a child and an elderly, male.

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Branchial cystII.

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• Its is a remnant of a 2nd branchial cleft • Lines by squamous epithelium, contains thick and turbid fluid full

of cholesterol crystal

• Present since birth, but majority present between ages 15-25 years. Can present in 40s & 50s

• Males = females.

Presentation : AsymptomaticPainful if become infected

Branchial cyst

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Exam :Fluctuant swelling, may transilluminate, mostly softOvoid in shape, 5-10 cmThe local deep cervical lymph nodes should not be enlarged, if so reconsider your diagnosis (TB abscess or papillary carcinoma of the thyroid).

Complications: 1. Infection 2. Branchial fistula (sinus)

Investigation:Ultrasound Fine Needle Aspiration

Treatment: Controlling infection if present, then surgical excision.

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Thyroglossal cystIII.

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• It is a fibrous cyst that forms from a persistent thyroglossal duct.• Most common congenital neck mass

• It can occur anywhere between the base of the tongue and the isthmus of the thyroid gland

• They are commonly found in two sites: between the isthmus of the thyroid gland and the hyoid bone, and just above the hyoid bone.

Thyroglossal cyst

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• Any age, common in ages between 15–30 years old. • More common in women. Presentation :• Asymptomatic midline mass in the neck.• Dysphagia (if large)• Pain, tenderness and increase in size (if infected). Exam :• Their size varies between 0.5 to 5 cm in diameter.• The mass moves with protrusion of the tongue.

Complications: 1. Infection 2. Thyroglossal sinus

3. Thyroid carcinoma (1-2%)

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Investigation:UltrasoundCT scan

Treatment: surgical resection, removal ofWhole thyroglossal tract = Body of hyoid bone + Suprahyoid tract through tonge base (Sistrunk procedure), to prevent recurrence.

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Thyroglossal cyst Thyroglossal sinus

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Dermoid cystIV.

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Dermoid cyst

• It is a cystic teratoma that contains developmentally mature, solid tissues (skin, hair, sweat glands…).

• Usually single, and benign.• It may be noticed at birth, but it usually becomes obvious a

few years later when it begins to distend.

• Are common in the neck and face in the midline, and at the inner and outer end of the upper eyebrow.

• Rarely large enough to cause any serious mechanical disability.

• Rarely becomes infected.

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• Surface: smooth.• Shape and size: usually ovoid or spherical and 1-2 cm in

diameter.• Consistency: Solid or hard.• Relations: deep to the skin (in the subcutaneous tissue),

mobile.• Nontender.• Does not move with protruding the tongue

Treatment: surgical excision.

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Cystic hygromaV.

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Cystic hygroma

• It is a congenital collection of lymphatic sacs that are derived from clusters of lymph channels that failed to connect and become normal lymphatic pathways.

• They contain clear, colorless lymph.

• Commonly found at the base of the posterior triangle• Present at birth or within first few years of life.• The only complaint is the lump, and the concern about

the disfigurement by the parents.• May present with a complication: - Breathing and swallowing difficulty - Infection - Bleeding in the cyst

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• Could be lobulated or flattened in shape, vary in size.• Not tender.

• They usually develop in the subcutaneous tissues. • They are close to the skin and contain clear fluid, their

distinctive physical sign is a brilliant translucence.

Treatment: surgical excision & removing all the abnormal tissue.

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Sternomastoid tumorVI.

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• Ischemic contracture of a segment of sternomastoid muscle.• Due to trauma at birth infraction and edema.• Later on the lump disappear and the abnormal segment becomes

fibrotic and contracted, leading to torticollis.

• Attempts to turn the head straight may cause pain or distress. • Most often located in the inferior to the middle third of the

sternocleidomastoid muscle.

Treatment:• Physiotherapy is recommended to achieve full range of motion.

Some patients have small areas of residual fibrosis.• Surgery is reserved for patients in whom torticollis is present for

more than one year, or if craniofacial asymmetry develops.

Sternomastoid tumor

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50 year old female presents with a pulsatile, compressible mass that refills rapidly on the release of pressure, and can be moved from side to side but not up and down. Diagnosis?

Carotid body tumor

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Carotid body tumorVII.

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• Rare tumor of the chemoreceptor tissue in the carotid body.• Usually benign, but can occasionally be malignant (3%).• Appear 40-60 years of age.• The common presentation is a painless slowly growing

lump.• Found in the upper part of the anterior triangle.• Size: 2-3cm to 10 cm in diameter. • Non tender solid, hard mass.• Moves from side to side but not vertically.

Carotid body tumors

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Pulsatile; the common carotid artery can be felt below the mass, and the external carotid artery may pass over its superficial surface.

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Investigations:1. Carotid angiogram to demonstrate the carotid bifurcation. 2. MRI & CT

Biopsy and FNA are contraindicated.

Treatment:o Surgical resection for small tumors in young patients.o Irradiation or close observation in elderly (surgery is best

avoided in elderly due to it’s serious complication).

Possible complication of the surgery:1. Postoperative hemorrhage or late stroke2. Superior laryngeal nerve injury.

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Pharyngeal pouchVIII.

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• It is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle.

• In middle and old age.

• Most patients have symptoms but no abnormal physical signs.

• Associated with halitosis, recurrent sore throat, regurgitation with bouts of coughing and choking, and may cause dysphagia.

• The swelling my change in size and often disappears.

• Pressure on it causes gurgling sounds and regurgitation.• Mostly there’s no palpable swelling, but when appears it is behind

the sternomastoid muscle, below the level of thyroid cartilage.

Pharyngeal pouch

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