1. neck mass aetiology, diagnosis & management
PROF. SHAHID A. SHAH FRCSEd (UK)
Consultant & Head, Department of ENT,
Prince Mohammad Bin Abdul Aziz Hospital,
Riyadh, Kingdom of Saudi Arabia.

2. Neck mass Neck masses are not infrequent in clinical practice
Entails adequate assessment
Identification
Determine etiology
Prompt management
Neck mass

3. Any abnormal enlargement, swelling or growth from the level of skull base and lower border of mandibles to the clavicles.
NECK MASS

4. NECK MASS - AnATOMY

5. anatomy Anterior & Posterior cervical triangles
Hyoid bone, thyroid cartilage, and cricoid cartilages - central portion of the neck.
Thyroid gland - midline below the thyroid cartilage.
Carotid arteries - pulsatile
Sternocleidomastoid muscles - deep jugular lymph nodes.
Parotid glands - preauricular area, extending below the angle of the mandible, inferior to the ear-lobe.
Submandibular glands - triangle bounded by the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and the body of the mandible.
Lymph nodes - most common neck mass. Fixed, firm, or matted lymph nodes and nodes larger than 1.5 cm require further evaluation.
anatomy

6. classification Onset Age Location Congenital Acquired Adult Paediatric
Midline
Lateral
classification

7. Differential diagnosis
Congenital
Inflammatory/Infectious
Trauma
Metabolic, Idiopathic & Autoimmune
Neoplasm
Differential diagnosis

9. congenital Lateral Neck Central Neck Branchial anomalies - most common
Cysts, sinuses, and fistulae, may be present anywhere along the sternocleidomastoid muscle.
Cystic hygromas (lymphangiomas)
Dermoids
Central Neck
Thyroglossal duct cyst - most common
Thymic rests
congenital

10. INFLAMMATORY AND INFECTIOUS CONDITIONS
Inflammation
Lymph node group – reactive adenopathy
Submandibular nodes within the submandibular triangle
Jugular chain of nodes located along the internal jugular vein
Posterior-triangle nodes located between the sternocleidomastoid and trapezius musculature.
Chronic sialadenitis
Salivary stones or duct stenosis can result in gland hypertrophy and fibrosis
Mass within the salivary gland.
INFLAMMATORY AND INFECTIOUS CONDITIONS

11. INFLAMMATORY AND INFECTIOUS CONDITIONS
Infection
Bacterial and viral infections
HIV infection
Cat-scratch disease
Toxoplasmosis - generally presents as a single enlarged node in the posterior triangle
Infectious mononucleosis - acute pharyngitis, cervical adenopathy, and an elevated Epstein-Barr virus titer.
Fungal infections e.g. actinomycosis
INFLAMMATORY AND INFECTIOUS CONDITIONS

12. trauma Hematoma - may persist as firm mass because of fibrosis.
Pseudoaneurysm
Arteriovenous fistula
trauma

13. Metabolic, idiopathic & Autoimmune
Metabolic disorders are rare causes of neck masses.
Gout and tumoral calcium pyrophosphate dihydrate deposition disease
Idiopathic conditions
Inflammatory pseudotumor
Kimura's disease
Castleman's disease
Sarcoidosis.
Metabolic, idiopathic & Autoimmune

14. neoplasm Benign Masses Malignant Masses
Lipomas, hemangiomas, neuromas and fibromas.
Hemangiomas typically occur with cutaneous manifestations and are relatively easy to recognize.
Neuromas may arise from nerves in the neck and rarely present with sensory or motor deficits.
Malignant Masses
Malignant neoplasm in the neck can arise as a primary tumor or as metastasis (upper aerodigestive tract or a distant site)
Thyroid cancer,
Salivary gland cancer,
Lymphomas,
Sarcomas
Metastatic disease
neoplasm

15. Neck node metastasis patterns

16. Relative prevalence of neck mass etiologies
Type
Common
Uncommon
Rare
Acute
Cytomegalovirus infection
Epstein-Barr virus infection
Staphylococcal or streptococcal infection
Toxoplasmosis
Viral upper respiratory infection
Acute sialadenitis
Arteriovenous fistula
Bartonella henselae infection
Hematoma
Human immunodeficiency virus infection
Mycobacterium tuberculosis infection
Parotid lymphadenopathy
Pseudoaneurysm —
Subacute
Squamous cell carcinoma of the upper aerodigestive tract
Amyloidosis
Lymphoma
Metastatic cancer
Parotid tumor
Sarcoidosis
Sjögren syndrome
Castleman disease
Kikuchi disease
Kimura disease
Rosai-Dorfman disease
Chronic
Thyroid pathology
Branchial cleft cyst
Carotid body tumor
Glomus jugulare tumor
Glomus vagale tumor
Laryngocele
Lipoma
Thyroglossal duct cyst
Liposarcoma
Parathyroid carcinoma
Relative prevalence of neck mass etiologies

17. Neck mass 90% of adult neck masses are malignant
90% of pediatric neck masses are infective
Neck mass

19. Branchial cyst Congenital, epithelial cyst
Failure of obliteration of second branchial cleft
2nd decade of life, commonly, M=F
Lateral neck, anterior to SCM muscle
Smooth, round, fluctuant, non-tender, non-transilluminant
May have external opening(Branchial sinus) or both internal and external openings(Branchial fistula)
Investigations:
Sonogram
Ultrasound
CT scan
MRI
FNAC
Treatment
Medical
Surgery
Branchial cyst

20. Thyroglossal cyst Most common congenital neck cyst
Epithelial remnant of Thyroglossal tract lined by columnar or squamous epithelium and surrounded by fibrous capsule
Presents in midline between Hyoid bone & Thyroid cartilage(60%)
Any age, mostly children
Moves up on tongue protrusion
Breathing difficulty if high
Ultrasound, CT scan
TFTs, Thyroid scan
Sistrunk procedure
Thyroglossal cyst

21. Lymph node Acute lymphadenitis Acute URTI Tender lymph nodes
Anterior triangle
Responds to antibiotic treatment
Lymph node

22. Lymph node Metastatic lymphadenopathy Malignant head & neck tumours
Single/Multiple
Unilateral/Bilateral
Firm to hard
Fixed, usually, to deeper structures
FNAC
Neck dissection
Chemo-Radiotherapy
Lymph node

23. Lymph node Lymphoma Blood investigations CT scan Lymph node biopsy
Hodgkin’s
Non- Hodgkin’s
Blood investigations
CT scan
Lymph node biopsy
Chemo-radiotherapy
Lymph node

24. Lymph node Granulomatous lymphadenitis Multiple lymph nodes, usually
Painless, non-tender
Firm, metted
LRT/ GIT symptoms
FNAC
Sputum culture
Chest X-ray
Lymph node

25. Salivary gland Acute sialadenitis Viral or bacterial
Tender enlargement
Firm to fluctuant
Trismus, Odynophagia
Treatment:
Symptomatic
Antibiotic
Incision drainage
Salivary gland

26. Salivary gland Chronic sialadenitis Tumour Sialolithiasis Sialectasis
Sjogren’s disease
Tumour
Benign
Asymptomatic usually
Pleomorphic adenoma
Warthin’s tumour
Malignant
Painful & rapid growth,
Fixation
CN involvement
Mucoepidermoid carcinoma
Salivary gland

27. thyroid Diffuse enlargement Nodular enlargement
Toxic – Grave’s disease
Non-toxic – Hashimoto’s thyroiditis, Simple colloid goiter
Nodular enlargement
Solitary nodule – cyst, adenoma, neoplastic
Multinodular goiter – toxic, non-toxic
thyroid

28. thyroid Adults, mostly Midline/lateral, unilateral or bilateral
Painless, firm to hard, usually and limited lateral mobility
Moves up on swallowing
Obstructive aero-digestive symptoms
Voice changes
Symptoms related to thyroid gland function
Exposure to ionizing radiation
Thyroid function studies
FNAC
CT scan
thyroid

29. Thyroid mass treatment
Benign thyroid mass
Medical treatment
Surgery
Malignant thyroid mass
Radio-iodine treatment
External beam radiotherapy
Thyroid mass treatment

30. Neck abscess Parapharyngeal abscess Retropharyngeal abscess
Prevertebral abscess
Peritonsillar abscess
Ludwig’s angina
Neck abscess

31. Neck abscess Tender, fluctuant swelling Odynophagia
Breathing difficulty
Leucocytosis
CT scan
Incision drainage
Systemic antibiotic
Neck abscess

32. tumour Benign Malignant Lipoma Fibroma Neuroma Haemangioma
Squamous cell carcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Thyroid
tumour

33. Patient's age, size and duration of the mass - most significant predictors of neoplasia.1
Occurrence/duration of symptoms:
Acute symptoms (fever, sore throat, and cough) - adenopathy resulting from an URTI.
Chronic symptoms (of sore throat, dysphagia or dysphonia)- anatomic or functional changes in the pharynx or larynx.
Recent travel, trauma, insect bites or exposure to animals – inflammation/infection
Smoking, alcohol abuse or previous radiation treatment - malignant
history

34. Skin - premalignant or malignant lesions resulting from chronic sun exposure.
Otologic examination - sinus or fistula associated with a branchial anomaly.
Chronic sinusitis or pharyngitis - reactive adenopathy as the most likely cause of a neck mass.
Mucosal surfaces – ulceration, swelling, asymmetry
Tongue palpation may reveal occult lesions.
Larynx and pharynx - indirect or flexible laryngoscopy.
Neck examination
Neck
Mass
Physical examination

35. NECK MASS - assessment Laboratory tests Radiology FNAC Ultrasonography
Contrast enhanced CT
Non Contrast enhanced CT
CT Angiography
FNAC
NECK MASS - assessment

36. NECK MASS - assessment Ultrasonography
Distinguish cystic from solid lesions
Detect nodal size
Differentiate high-flow from low-flow vascular malformations
Guiding FNAB of non-palpable or small superficial lesions
Preferred initially in younger patient populations to reduce radiation exposure
Preferred to avoid contrast media–induced nephropathy in patients with underlying renal disease.
NECK MASS - assessment

37. NECK MASS - assessment Contrast enhanced CT Non contrast enhanced CT
Size, extent, location, and content or consistency of the mass
Contrast media may help:
Identify malignant lymph nodes that are not enlarged
Distinguish vessels from lymph nodes
Non contrast enhanced CT
Suspected swollen salivary glands due to sialolith obstruction
CT angiography
Pulsatile neck mass
NECK MASS - assessment

38. NECK MASS - assessment FNAB
Non involvement of underlying vital structures
Provide further information through cytology, Gram stain, and bacterial and acid-fast bacilli cultures
Avoids complications of open biopsy
Sensitivity - 77% to 97%, specificity - 93% to 100%
Contraindicated for a pulsatile/vascular origin mass
NECK MASS - assessment

39. Neck mass - management Treatment dictated by etiology Medical Surgical
Radiotherapy
Multimodality
Neck mass - management

40. Neck mass - management Persistent neck mass Diagnosis still elusive
Head & Neck Surgeon
Endoscopy
Nasopharyngoscopy
Direct Laryngoscopy
Oesophagoscopy
Biopsy
Suspicious site
High malignancy prevalence site
Pulmonologist/Thoracic surgeon
Neck mass - management

41. Neck mass - Management Excisional biopsy Frozen section
Neck dissection
Radiotherapy
Neck mass - Management