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A. Neck Anatomynavigator

  1. The neck is replete with a very high density of structures
    1. These include lymphatic, neural, vascular, muscular and glandular structures
    2. Each of these structures can give rise to the neck mass
  2. Triangles and zones of the neck
    1. Neck is divided into anterior (medial, midline), lateral and posterior compartments
    2. Anterior: from medial aspect of carotid sheath to medial aspect of carotid sheath
    3. Lateral: from carotid sheath to posterior border of sternocleidomastoid muscle
    4. Posterior: from posterior border of SCM to trapezius
  3. Embryology
    1. Complex embryology with the neck forming in utero from the branchial arches and clefts
    2. Abnormal development may lead to variety of defects:
    3. Branchial cleft cyst (no communication with skin or pharynx)
    4. Branchial cleft sinus (communicates with skin only)
    5. Branchial cleft fistula (communication between pharynx and skin surface)
  4. Typical Structures and Derived Neck Masses
    1. Lymph node and lymphangioma
    2. Aterteries and aneurysms
    3. Muscle and connective tissue can form rhabdomyosarcomas and fibrosarcomas
    4. Nerve eaths and schwannoma
    5. Thyroid neoplasms or goiter
    6. Salivary gland neoplasm
    7. Salivary glands and infections (eg. parotiditis)

B. Evaluationnavigator

  1. History
    1. Age > 40 increased (~80%) likelihood of neoplasia for all neck masses
    2. Smoking and alcohol use increase chance of squamous cell malignancy
    3. Recent history of infection suggests infectious nature of mass
    4. Important to consider history of tuberculosis, fungal infections, HIV status
    5. Associated upper aerodigestive tract symptoms
    6. Check for otalgia, pain, bleeding, odynophagia, dysphagia, hoarseness
    7. Systemic symptoms: weight loss, night sweats, chills
  2. Physical Examination
    1. Complete head and neck physical examination
    2. This includes scalp, ears, nose, oral cavity, teeth, oropharynx, hypopharynx and larynx
    3. Determine location of neck mass, whether single or multiple, size, tenderness, skin

C. Differential Diagnosis (by location)navigator

  1. Midline
    1. Dermoid cyst: usually above hyoid bone
    2. Thyroglossal duct cyst: at or near hyoid, often with a tract
    3. Thyroid neoplasms or nodules: below cricoid
    4. Delphian node: midline node associated with thyroid carcinoma
    5. Parathyroid adenoma
  2. Lateral (antero-lateral)
    1. Lymphadenopathy
    2. Submandibular gland neoplasm
    3. Carotid aneurysm or jugular venous ectasia: palpation for pulse and listen for bruit
    4. Lymphangioma (cystic hygroma): diffuse rubbery, usually in children
    5. Lateral extension of thyroid nodule or goiter
    6. Schwannoma of vagus or other nerve: often associated nerve paralysis
    7. Carotid body tumor: near hyoid bone
    8. Laryngocele: increase in size with Valsalva
    9. Others: lipoma, soft tissue neoplasms, sarcomas, neurofibroma
  3. Posterior
    1. Lipoma
    2. Soft tissue neoplasms
    3. Lymphadenopathy
    4. differential as above
      1. more common site of spread for sinus and nasopharyngeal spread
  4. Multiple Sites for Neck Masses
    1. lymphadenitis: same differential (see also below)
    2. lymphoma
    3. metastatic disease
  5. Lymphadenopathy Differential
    1. Infectious lymphadenitis
    2. typical bacterial: Streptococcus, Staphylococcus
      1. other bacterial: tuberculosis, scrofula, cat scratch disease, lyme disease
      2. viral lymphadenitis: EBV, CMV
      3. other infectious: blastomycosis, toxoplasmosis, HIV lymphoid proliferation
    3. Neoplastic
    4. metastatic: from squamous cell Ca (SCCA) of upper aerodigestive tract or from infraclavicular primary (esp. stomach, esophagus)
      1. lymphoma
    5. Branchial cleft cyst, sinus or fistula: history of recurrent infections, drainage, swelling often after upper respiratory tract infection

D. Diagnostic Testingnavigator

  1. Head and neck endoscopy (office):
    1. Office endoscopy with fiberoptic scopes is
    2. Often necessary to evaluate the larynx and hypopharynx
    3. Especially important in patients (smokers, alcoholism) at high risk for cancers
  2. Laboratory studies
    1. Consider CBC, HIV tests
    2. For infectious etiology consider PPD (TB), EBV, CMV, toxoplasmosis and/or lyme titers
    3. Other tests: ACE level (sarcoidosis), thyroid function, calcium levels
  3. Imaging
    1. CT/MRI: excellent first line choice for neck masses.
    2. Ultrasound
    3. good for thyroid evaluation
      1. for differentiating solid from cystic masses
      2. may help localize a small mass for fine needle biopsy (reduce sampling error)
  4. Thyroid scan may be indicated
  5. Chest Radiography
  6. Fine Needle Biopsy

E. Fine Needle Biopsy navigator

  1. Eventual procedure of choice for most neck masses
  2. Especially those with high suspicion for malignancy
  3. Sensitivity > 80% for detecting malignancy
  4. Material may be sent for PCR for cases of TB, toxoplasmosis, cat scratch disease
  5. Very accurate in cases of SCCA; less accurate for other malignancies
  6. Beware of false negatives--may be a sampling error
  7. Accuracy will depend on experience of cytopathologist
  8. Additional material: Gram stain / culture, fungal stain / culture, AFB stain / culture

F. Operative Evaluationnavigator

  1. Panendoscopy
    1. Consists of direct laryngoscopy, esophagoscopy, bronchoscopy
    2. Only for patients at high risk for SCCA of upper aerodigestive tract, prior to proceeding with open biopsy
  2. Open biopsy of the neck mass: only after search for a primary cancer has yielded no source

G. Treatmentnavigator

  1. Infectious mass: treatment directed at organism demonstrated by culturing
  2. Masses that have "abscessed" may need incision and drainage
  3. Congenital mass: surgical excision
  4. Acutely inflamed mass may need incision and drainage and then staged resection
  5. Neoplastic mass
    1. Treatment must be tailored to primary site (if any), as well as the mass
    2. Treatment usually includes the regional lymphatics (such as surgical neck dissection)

References navigator

  1. Alvi A and Johnson JT. 1995. Postgrad Med. 97(5):87 abstract