Evaluation and Management of the Patient with a Neck Mass

Bastaninejad, Shahin, MD, ORL and HNS Specialist

Anatomy

History and P.Exam.

Historical Points

• Age:– Up to 15yrs (pediatrics) more than 90% benign– 16 to 40 (young adult) – More than 40yrs (older adults) 80% neoplasm

80% of them malignant (secondary>>primary)

• Time course• immunodeficiency

• Prior trauma

• Travel, Irradiation, Surgery

• Associated symptoms fever, dysphagia, weight

loss, otalgia, hearing loss, respiratory difficulties

• Perform a FULL head and neck examination

Diagnostic imaging

Modality Basic Indications

Ultrasound Good for pediatric neck masses, thyroid masses. Differentiates cystic versus solid.

Computed tomographyWorkhorse imaging modality for adult neck masses. Provides three-dimensional relationships, excellent detail of mucosal disease and involvement of adjacent bone.

Magnetic resonance imaging

Superior soft tissue delineation. Good for lesions of the salivary glands and tongue (where dental amalgam may obscure the view on a CT). Modality of choice for determining nerve enhancement. Consider for thyroid imaging in cases necessitating radioiodine.

Radionuclide scanning Useful for midline lesions in children—differentiates functioning from nonfunctioning tissue.

Positron emission tomographyUseful for staging of head and neck malignancies. Can be used in cases of unknown primary malignant neck masses or treated neck disease.

Angiography/magnetic resonance angiography/computed tomography angiography

Useful for lesions encasing the carotid and vascular lesions. Conventional angiography should be considered for preoperative assessment in cases of potential carotid artery sacrifice or where embolization is required.

Plain radiograph Generally should not be considered in the workup of a neck mass.

Table 116-1   -- Imaging of Neck Masses

Initial w/u of the unknown neck mass

• FNA if unsuccessful or less informative

consider Re-FNA failure again consider core

needle Bx Failure again excisional Bx and if

it was SCC, consider simultaneous neck

dissection procedure

Differentials for Unknown neck mass

Inflammatory causes

• The most common neck masses• LAP:

– typically subside without tx – sometimes it become necrotic and an abscess forms

(Staph./Strep.)

• Granulomatous disease: TB, atypical mycobac., actinomycosis, cat scratch, syphilis.– FNA better than excision (because of the risk of non-

healing wound)

• Sialadenitis and Sialolithiasis

– Abx

– Hydration

– Warm compresses

– Massage

– sialogogues

Congenital neck masses

• TGDC

– In pediatric they are second in frequency only to LAP

– Elevates in the neck with tongue protrusion

– If it becomes infected: Avoid I&D Choice is

Aspiration and Abx.

– Main procedure is Sistrunk procedure

• Branchial cleft anomalies

– Anomalies: cyst, sinus, fistula

– 30% of the pediatric neck masses

– 95% of them 2nd Arch anomaly:

• Manifest as a lateral neck swelling associated with an URI

• Like TGDC, avoid I&D

• Tract pathway is lateral to the ICA, and enters to the

pharynx at the tonsillar fossa

• Its swelling bulk or draining tract is anterior to the SCM

muscle

• 1st Branchial Cleft anomaly

– 1% of branchial cleft anomalies

– Associated with VII nerve

– Fistula, cyst & sinuses located between EAC and the

angle of the mandible

• Type 1: EAC duplication, contain ectodermal elements, it’s

lateral to the VII nerve

• Type 2: Contain ectodermal and mesodermal elements

(mesocartilage), it’s deep to the VII nerve

• 3rd and 4th BCA

– Extremly uncommon

– Swelling or sinus tract in the lower neck, anterior to

the SCM muscle

– 3rd: Deep to the CA, pierce thyrohyoid membrane and

enters the pharynx at pyriform sinus

– 4th: Deep to the CA, close to the thyroid gland, enters

pyriform sinus or cervical esophagus

• Dermoid cyst: contains ectodermal and

endodermal elements

• Teratomas:

– all three germ layers

– Less than 2% of all body teratomas are in H&N, most

commonly: neck and nasopharynx

• Lymphangioma most common in posterior

triangle

• Hemangioma:

– Commonly occure in H&N and it’s present at birth

– Phases:

• Rapid expansion (6-12mo)

• Stable phase; no/minimal change occures

• Involution; usually begins by 24mo

– 50% complete in 5yr age

– Nearly all tumors regress by 10-12yr s age

Neck Neoplasms

Primary neoplasm of the neck

• Lymphoma:– Most common H&N malignancy in Ped.– 2nd most common overall H&N malignancy second

only to SCC (SCC is the most common H&N cancer)

– Non Hodgkin (*5) > Hodgkin– 90% B cell

• Thyroid neoplasm:– Most common neoplastic anterior neck masses in all

age groups– More than 90% of all thyroid nodules are benign

• Malignancy probability is greater in very young children, very old age population and males

• Salivary gland neoplasm– 1% of all H&N masses– MEC is the most common salivary malignancy

• Salivary gland neoplasm, Continue:• %80 is from parotid gland %80 benign majority: benign

mixed tumor• %15 SMG %50 malignant• %5 S.Lingual & minor glands More than %75 malignant

– Neurogenic Neoplasm:• Schwanoma

– Is the most common neurogenic tumor– Parapharyngeal space is a common location

• Neurofibroma– There is a %2-6 risk of malignant degeneration (malignant nerve sheet

tumor)

• Neurogenic Neoplasm, Continue:

– Neuroblastoma, ganglioneuroblastoma, . . .

– Neuroma it is a complication of truma, mainly

greater auricular nerve

• Paraganglioma neuroectodermal origin

– Carotid body (angiographyLyre’s sign)

– Jugulotympanic region usually not a neck mass

– Vagus nerve

• Lipoma

Work up for Unknown Primary, SCC of the Neck

1.  complete physical examination   (inspection and palpation) of all head and neck subsites

Oral cavity

Oropharynx

Thyroid

Salivary glands

Face/scalp/neck skin

2.   Fiberoptic endoscopy examination

Nasal cavity

Nasopharynx

Oropharynx

Hypopharynx

Larynx

3.    Fine-needle aspiration Table 116-2   -- Steps in the Workup of an Unknown Primary Squamous Cell Carcinoma of the Neck

4.   Primary imaging

Head and neck (computed tomography or magnetic resonance imaging)

Chest (radiograph or computed tomography)

5.  Secondary imaging

Positron emission tomography

6.    Panendoscopy/ Directed mucosal site sampling

Include laryngoscopy, bronchoscopy, esophagoscopy, and ipsilateral tonsillectomy.

Pay close attention to the tongue base and hypopharynx.

Thank You!