1. Neck Mass
Yonatan Avraham Demma

2. DIAGNOSIS Patient history Physical examination Differential diagnosis
Imaging studies
Blood test

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

4. …the age of the patient.

5. 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.

6. 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.

7. 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

8. Differential diagnosis
ANATOMY
Differential diagnosis

10. 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

11. 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

12. 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.

13. POSTERIOR/LATERAL NECK
Contains:
lymph node,
the spinal accessory nerve,
the cervical plexus.
the brachial plexus
subclavian vessels.

14. Differential Diagnosis
Congenital neck mass
Inflammatory Neck mass:
Infectious
Non infectious
Neoplastic Disorder

16. CONGENITAL NECK MASSES
BRANCHIAL CLEFT CYSTS
THYROGLOSSAL DUCT CYSTS
LARYNGOCELES
PLUNGING RANULAS
LYMPHANGIOMAS
HEMANGIOMAS
TERATOMAS - DERMOID CYSTS
THYMIC CYSTS
STERNOCLEIDOMASTOID TUMORS OF INFANCY

17. 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.

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

21. incision and drainage procedures should be avoided
Treatment
initial control of the infection
surgical excision of the cyst and tract.
incision and drainage procedures should be avoided

22. 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.

24. 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

25. 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,

26. Laryngocele

27. 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.

28. 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

29. 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 failure
Systemic corticosteroids or surgical laser excision may be warranted in such cases.

31. 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.

32. 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.

33. 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.

34. 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

35. VIRAL LYMPHADENOPATHY
REACTIVE VIRAL LYMPHADENOPATHY
HIV-ASSOCIATED INFLAMMATORY DISORDERS

36. 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.

37. 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.

38. 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.

39. 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

40. BACTERIAL LYMPHADENOPATHY
Suppurative Lymphadenopathy
Toxoplasmosis
Tularemia
Brucellosis

41. 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.

42. 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).

43. 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.

44. 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

45. GRANULOMATOUS DISEASES
cat-scratch disease,
actinomycosis,
atypical mycobacteria,
tuberculosis,
atypical tuberculosis,
sarcoidosis.

46. 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.

47. 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

48. 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.

49. 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.

50. 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.

52. 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

53. NONINFECTIOUS INFLAMMATORY DISORDERS
Sinus histiocytosis – Rosai-Dorfman disease
Kawasaki disease
Castleman disease

54. 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.

55. 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.

56. 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

57. NEOPLASTIC DISORDERS METASTATIC LYMPH NODE THYROID MASSES LYMPHOMAS
SALIVARY NEOPLASMS
PARAGANGLIOMAS
LIPOMAS
SOLITARY FIBROUS TUMOR

58. 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.

60. 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.

61. 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.

62. 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.

63. 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

64. 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.

65. 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.

66. 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.

67. Imaging Studies CT MRI. Ultrasonography Chest X-rays
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

68. 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.

69. 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.