An approach to the neck masses

BY:HARDI H. QADER

KIRKUK UNIVERSITY COLLEGE OF MEDICINE

Mass: a lump or an aggregation of coherent material (soft tissue mass)

Lump: an irregularly shaped mass or piece (breast lump) Swelling: an abnormal enlargement of a part of body,

typically as a result of an accumulation of fluid

Cyst: a swelling consisting of collection of fluid in the sac which is lined by epithelium or endothelium

Anatomy

The neck is the transitional area between the base of the cranium superiorly and the clavicles inferiorly.

The neck joins the head to the trunk and limbs, serving as a major conduit for structures passing between them.

Anatomic landmarks:Anteriorly: the neck starts from lower border of mandible to the upper border of the sternum (suprasternal notch) and clavicles .

Posteriorly: from external occipital protuberance to the spinous process of C7

Anatomy of the neck by triangles

Anterior triangle more subdivided:

Posterior triangle more subdivided:

Surface Anatomy

Anatomy of the Lymph nodes of the neck

Surface Anatomy

Patient presented with neck lump, swelling or mass, what is your work

up?

History

History: 1. Age: Neck masses in children and young adults are more

commonly infl ammatory than congenital, and rarely neoplastic.

In adult always there is suspension to be neoplastic.

2. Location Medline swellings

Lateral swellings

3. Duration Inflammatory disorders are usually acute in onset, and resolve

within 2–6 weeks. Cervical lymphadenitis is often associated with recent upper

respiratory tract infection. Congenital masses are often present from birth as small,

asymptomatic masses, which enlarge rapidly after mild upper respiratory tract infection.

Metastatic carcinoma tends to have a short history of progressive enlargement.

Transient post-prandial swelling in the submandibular or parotid area suggests salivary gland duct stenosis that may lead to obstruction.

Bilateral diffuse tender parotid enlargement is most commonly mumps in children and sialosis in adults.

4. Discharge Suggest infection mostly complicated congenital

pathologies due to fistula or sinus formation with supper added infection (Abscess)

5. Others Family Hx: TB Social Hx: smoking, alcohol, and history of travel and contact

Examination

Physical examination1. General examination (JACOL + Vital signs) 2. Full head and neck examination The oral cavity and nasopharyngeal Mucosal surfaces, is helpful, especially when suspecting

malignancies. Palpate the thyroid The lumps relation to muscles, trachea, and hyoid bone! The location, mobility and consistency of a neck mass can

often place it within a general aetiological group – congenital, nodal/inflammatory, vascular, salivary or neoplastic.

Do not forget to chick the abdomen !!!!

Congenital masses are generally soft, smooth and mobile, may be tender when infected.

Inflammatory adenopathy is tender, mobile mass Chronic inflammatory masses and lymphomas are

often non-tender and rubbery and may be either mobile or feel like matted adenopathy.

In older age groups, the submandibular and parotid glands become ptotic and mimic neck lumps, and can cause concern to patients.

Features rise suspicion of malignancy:1. voice change, 2. odynophagia, 3. dysphagia, 4. haemoptysis 5. previous radiation, especially with thyroid tumours.6. oral lesions, recent trauma, globus sensation,7. referred ear pain, muffled or decreased hearing8. constitutional symptoms (e.g. night sweats, anorexia, weight

loss), 9. unilateral nasal discharge or epistaxis, 10. family history of cancer and previous tumours

Diagnostic tools

Diagnostic studies1. Investigations:

I. Full blood countII. Erythrocyte sedimentation rate (ESR).III. Throat swab: occasionally helpful, but must be sent immediately in the proper medium.IV. Viral serology: Epstein–Barr virus, cytomegalovirus and toxoplasmosis.V. Thyroid function tests ultrasound in all cases of thyroid enlargement.

2. Images:I. Ultrasonography is useful in differentiating solid from cystic masses.II. Chest X-ray in smokers with persistent neck lump.III. CT scan and MRI to determine the extent of the masses

3. Fine needle aspiration biopsy (FNAB) is helpful for the diagnosis of neck masses and any neck lump that is not an obvious abscess and persists following antibiotic therapy.

A negative result may require a repeat FNAB, ultrasound-guided FNAB or even an open biopsy.

Treatment is differ according to the diagnosis

Characteristics of non-malignant neck lumps1. Cystic hygroma (Lymphangiomas) It is a congenital lesion usually present

within the first year of life.(post. Triangle) Usually remain unchanged into adulthood Is soft, cystic, multilocular, partially

compressible and brilliantly transilluminant. and may present with pressure effects.

CT or MRI may help define the extent of the neoplasm

Treatment of lymphangiomas includes injection with picibanil or excision for easily accessible lesions or those affecting vital functions.

2. Haemangiomas Often appear bluish and are

compressible. CT or MRI may help define the

extent of the neoplasm, especially intrathoracic.

Treatment : (depend on site, size and severity) most often resolve spontaneously within the first decade.

surgical treatment is reserved for lesions with rapid growth involving vital structures, which fail medical therapy (cs, laser or oral propranolol in infantile type).

3. Branchial cleft cysts Reminant of branchial cleft (2nd). Most commonly occur in the second or

third decades! Pain +/- (severe throbbing pain) Usually presents as a smooth, fluctuant

nontender (tender) , nontransluminal mass mobile forwards and downwards, underlying the anterior border of the sternomastoid muscle.

Branchial fistula or sinus ! Primary treatment is with control of

infection by antibiotics, followed by surgical excision.

4. Thyroglossal duct cyst This is a common congenital midline neck

mass. Sometimes at the lateral edge of the

thyroid cartilage. Pain and tenderness +/- Can be moved transversally but can not

be moved vertically Elevates on protrusion of the tongue. Treatment is with initial control of

infection with antibiotics, followed by surgical excision including the mid-portion of the body of the hyoid bone (Sistrunk’s procedure). Occasionally, these lesions may become infected and resolve, or persist following surgery as a thyroglossal fistula.

5. Lipoma

Lipomas are the most common benign soft tissue neoplasm in the neck. They are poorly defined, soft masses usually presenting after the fourth decade.

They are usually asymptomatic, soft to feel and deep to the skin.

FNAC or MRI Scan can confirm the diagnosis. Surgery is indicated when the lump is increasing in size,

cosmesis, or when there is doubt about the accuracy of diagnosis.

6. Sebaceous cysts

These are common masses occurring most often in older people but can occur at any age.

They are slow growing, but sometimes fluctuant and painful when infected.

Diagnosis is made clinically; the skin overlying the mass is adherent and a punctum is often identified.

Excisional biopsy confirms the diagnosis.

7. Cervical lymphadenopathy

Acute lymphadenitis tender swelling Antibiotic trial, Less acute

inflammatory nodes generally regress in size over 2–6 weeks.

If the lesion does not respond! biopsy

8. TB cervical lymphadenitis Upper and middle deep cervical LN Onset: gradually Pain: +/- Systemic symptoms unusual in young (occurs with

elderly) Abscess (painful, increase size, and skin

discoloration) Mass: indistinct, firm, matted, fluctuate! Temperature! (Cold abscess)

• Treatment with anti TB (6-9 months)RifampicinEthambutolINHPyrazinamide

9. Carotid body tumour Rare tumour of chemoreceptors (40-60

years). Slow-growing painless some time

pulsating lump may be bilateral. Side to side movement Symptoms of transient cerebral

ischemia! Potato tumours (hard, non tender) Palpation may induce vasovagal

attack Biopsy is contraindicated MRI

angiography is the investigation of choice.

Surgical removal is based on patient factors and presenting symptoms.

10.Pharyngeal pouch diverticulum of the pharynx through the

gap between the horizontal fibres of the cricopharyngeus muscle below and the lowermost oblique fibres of the inferior constrictor muscle above.

history of halitosis regurgitation of froth and food. There is no bile or acid taste to it.

Pressure on the swelling causes gurgling sounds and regurgitation

Treatment: cricopharyngeal myotomy

11.Ludwing’s angina Rare but serious connective tissue infection

of the floor of the mouth Mostly due to dental infections Sings of inflammation present Treatment: drainage of pus + antibiotic to

cover aerobes with anaerobes

12.Thyroid masses Thyroid neoplasms are a common

cause of anterior compartment neck masses in all age groups, with a female predominance, and are mostly benign.

Fine needle aspiration of thyroid masses has become the standard of care and ultrasound may show whether the mass is cystic.

Unsatisfactory aspirates should be repeated, and negative aspirates should be followed up with a repeat FNAC and examination in 3 months’ time.

Characteristics of malignant neck lumps

1. LYMPHOMAS Painless lump, nontender smooth and discrete Slow growing Patient Presented with malaise, wt. loss, pallor. Fever, rigor and hepatosplenomegaly Mediastinal mass (SVC syndrome) Abdomen pressure on IVC may cause bi lateral leg oedma other lymph nodes in the axilla, groin and abdomen

should be examined Treatment: according to stage (radiosensitive)

2. METASTATIC LYMPH NODES Upper cervical lymph nodes (upper aerodigestive tract). Accessory chain of nodes in the posterior triangle

(Nasopharyngeal malignancies). In many cases (Occult primary) most common sites are tonsil, base of

tongue, nasopharynx and pyriform sinus. Virchow's LN (toisier’s sign) abd. And thoracic malignancies Painless, nontender, and hard masses Work up: Search for primary and deal with it

To be a successful surgeon you need the

eyes of a hawk, the heart of a lion, and a hand of a

lady

Thank you