Neck Masses

Presented by Wan Nabilah

Supervised by Prof. Mohammad Khammash

Anatomy of the neck

(central & lateral)
Central neck includes midline
structures such as the hyoid
bone, thyroid and cricoid
cartilages, the thyroid isthmus
and the trachea

The sternocleidomastoid
muscle divides the lateral
neck into 2 major triangles:

Anatomical regions of the neck

Lymph nodes of the head and neck

Approach to neck
masses
History
Physical Examination
+/- Investigations

History

Age

Mass growth pattern : duration,size, painful, skin changes, other masses

Head & neck symptoms

Review of systems

Fever, night sweats, weight loss, pallor, itching Lymphoma

Loss of appetite & weight, pulmonary, alimentary or skeletal symptoms

Neoplasm

High spiking fever, rigors, general malaise Acute infection

Past medical history : past malignancy, previous infection

Family history : malignancy

Social history : smoking, alcohol, illicit drug use, previous irradiotion,

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occupational exposures, travel history)

Physical Examination

Inspection

Mass localization, Site

Neck masses: site

Midline

Thyroid
Dermoid cyst
Thymic cyst
Lymphadenopathy

Lateral

Anterior triangle

Posterior triangle

Lymphadenopathy
Branchial cyst

Lymphadenopathy
Cystic hygroma

Shape, color

Relation to muscles (muscle contraction)

Relation to trachea (swallowing)

Relation to hyoid bone (tongue is protrusion)

Palpation: temperature, tenderness, mobility, fluctuation, edge,

size, surface, consistency, pulsation.

Percussion for retrosternal goiter

Auscultation for bruits

Complete Head & Neck Examination (Mouth, ENT, skin, LNs,

thyroid, cranial nerves)

Systemic examination (RS & GI)

Investigations

Laboratory studies

When the history or physical examination does not suggest

transient reactive lymphadenopathy as the cause of a neck
mass.

Persistence of a newly discovered neck mass beyond three

weeks.

CBC, TFT

ESR, blood culture

EBV, CMV serology

Tuberculin skin test

Investigations

Imaging studies

Chest X Ray

Contrast CT scan of the neck

US

MRI orPET/CT scanning for follow-up.

Diagnostic studies:

FNAB (inflammatory vs neoplastic masses)

o Biopsy should never be used before excluding lesions such as

a carotid body tumor, an aneurysm or a pharyngeal pouch.

Core needle biopsy

Excisional or incisional biopsy

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Neck Mass

Congenital

Midline :
1- Thyroglossal Cyst
2- Dermoid Cyst

Acquired

Lateral :
1- Branchial Cyst
2- Muscular Mass
3- Cystic Vascular
4- Cystic Hygroma

1- Lymphadenopathy
2- Infectious
3- Neoplastic
4- Primary Reticulosis
11Cyst
5- Sebaceous

I.

Cervical
lymphadenopathy
Reactive
Reactive viral
viral
lymphadenopathy
lymphadenopathy

Tuberculous
lymphadenitis

Metastatic
tumors
Primary
neoplasms

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Enlargement of the cervical lymph glands is the

commonest cause of a swelling in the neck.

The four main causes of cervical lymph gland enlargement

are:

1. Infection: non-specific tonsillitis, TB, glandular fever,

toxoplasmosis, cat scratch disease.
2. Metastatic tumor: from the head, neck, chest and
abdomen.
3. Primary tumor: lymphoma, lymphosarcoma,
Reticulosarcoma.
4. Sarcoidosis.

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This child presented with a swelling in his

neck post upper respiratory tract
infection, it was firm, tender and mobile.
Diagnosis?

Reactive viral lymphadenopathy (tonsillitis)

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Reactive viral
lymphadenopathy

The upper deep cervical glands are most often

affected.

The common presenting symptom is a painful lump just

below the angle of the jaw.

Usually associated with tonsillitis in young children.

Mobile

Treatment is usually by treating

the underlying cause.
(Antibiotics)

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Tuberculous lymphadenitis

Upper deep cervical gland, usually with no generalized

infection.

Children, young adults and elderly.

Gradual onset of a lump in the neck +/- pain (pain if it

grows rapidly and necrose).

Usually not tender with normal color.

In early stages the glands are firm,

discrete & between 1-2 cm in
diameter.

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 As caseation increases and the glands necrose it forms

indistinct, firm mass (matted together).

Tuberculous abscess:
The swelling increases in size, becomes more painful, with
discoloration of the overlying skin and normal temperature
(cold abscess).
There may be tachycardia, fever, anorexia 17
and general
malaise.

Treatment:
A full course of antituberculous chemotherapy is given.
Small nodules are observed & should be excised if they enlarge.
Tuberculous abscess: drainage (aspiration or incision) +
continuation of medical therapy.
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Tuberculous lymphadenitis

A chronic tuberculous sinus

that has become
secondarily infected
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Metastatic tumors
Metastatic deposits of
cancer cells are the
commonest cause of cervical
lymphadenopathy in adults.
Most common in ages
between 55-65 years.
More common in men.
The patient usually presents
with painless hard, enlarged
lymph glands in the neck.
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The site of the affected

glands gives a crude
indication of the site of the
primary lesion:

Lesions above the hyoid bone

drain into the upper deep
cervical glands.

The larynx & thyroid drain

into the middle & lower
cervical glands.

An enlarged supraclavicular
lymph gland commonly
indicates intraabdominal or
thoracic disease. (ex.
Virchows gland/ Troisier'ssign).

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Primary cancers in H&N do not cause anorexia and

weight loss, they may have local symptoms (sore tongue,
hoarse voice..)

If the primary tumor is in the chest (cough or

hemoptysis), or the abdomen (dyspepsia or abdominal
pain) + general symptoms of anorexia and weight loss.

Normal color, may be pale or blotchy red (if large

enough to stretches or infiltrates the skin).

Not tender, variable sizes.

Stony hard.

Tethered to the surrounding structures, so they can

usually be moved in transverse direction but not
vertically.

FNAB is the STANDARD of diagnosis for neck masses If

you suspect malignancy (90% true diagnosis).
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Primary neoplasms of the

lymph glands

The most common is the malignant lymphoma (Hodgkins &

Non-Hodgkins)

Two peak; 15-35 years and above 50 years.

Males are more often affected.

Painless, slowly growing lump in the neck

Usually in the posterior triangle.

Solid & rubbery in consistence, not tender, usually

associated with pruritus.

General symptoms (malaise, weight loss, pallor, itching,

fever and rigors)

Treated by radiotherapy and chemotherapy.

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Lymphoma in the posterior triangle, in a child and an

elderly, male.

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II
.

Branchial cyst

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Branchial cyst

Its is a remnant of a 2nd branchial cleft

Lines by squamous epithelium, contains thick and turbid fluid full

of cholesterol crystal

Present since birth, but majority present between ages 15-25

years. Can present in 40s & 50s

Males = females.

Presentation :

Asymptomatic
Painful if become infected
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Exam :

Fluctuant swelling, may transilluminate, mostly soft

Ovoid in shape, 5-10 cm
The local deep cervical lymph nodes should not be
enlarged, if so reconsider your diagnosis (TB abscess or
papillary carcinoma of the thyroid).

Complications: 1. Infection

Investigation:

2. Branchial fistula (sinus)

Ultrasound
Fine Needle Aspiration

Treatment: Controlling infection if present, then surgical

excision.
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III.

Thyroglossal cyst

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Thyroglossal cyst

It is a fibrous cyst that forms from a persistent thyroglossal duct.

Most common congenital neck mass

It can occur anywhere between the base of the tongue and the
isthmus of the thyroid gland

They are commonly found in two sites: between the isthmus of

the thyroid gland and the hyoid bone, and just above the
hyoid bone.
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Any age, common in ages between 1530 years old.

More common in women.

Presentation :

Asymptomatic midline mass in the neck.

Dysphagia (if large)

Pain, tenderness and increase in size (if infected).

Exam :

Their size varies between 0.5 to 5 cm in diameter.

The mass moves with protrusion of the tongue.

Complications: 1. Infection

2. Thyroglossal sinus

3. Thyroid carcinoma (1-2%)

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Investigation:

Ultrasound
CT scan

Treatment: surgical resection, removal of

Whole thyroglossal tract = Body of hyoid bone + Suprahyoid tract through tonge base
(Sistrunk procedure), to prevent recurrence.

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Thyroglossal cyst

Thyroglossal sinus

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IV.

Dermoid cyst

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Dermoid cyst

It is acysticteratomathat contains developmentally

mature, solid tissues (skin, hair, sweat glands).

Usually single, and benign.

It may be noticed at birth, but it usually becomes obvious a

few years later when it begins to distend.

Are common in the neck and face in the midline, and at the
inner and outer end of the upper eyebrow.

Rarely large enough to cause any serious mechanical

disability.

Rarely becomes infected.

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Surface: smooth.

Shape and size: usually ovoid or spherical and 1-2 cm in

diameter.

Consistency: Solid or hard.

Relations: deep to the skin (in the subcutaneous tissue),

mobile.

Nontender.

Does not move with protruding the tongue

Treatment: surgical excision.

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V.

Cystic hygroma

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Cystic hygroma

It is a congenital collection of lymphatic sacs that are

derived from clusters of lymph channels that failed to
connect and become normal lymphatic pathways.
They contain clear, colorless lymph.

Commonly found at the base of the posterior triangle

Present at birth or within first few years of life.

The only complaint is the lump, and the concern about

the disfigurement by the parents.

May present with a complication:

- Breathing and swallowing difficulty - Infection

Bleeding in the cyst

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Could be lobulated or flattened in shape, vary in size.

Not tender.

They usually develop in the subcutaneous tissues.

They are close to the skin and contain clear fluid, their
distinctive physical sign is a brilliant translucence.

Treatment: surgical excision & removing all the abnormal

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tissue.

VI.

Sternomastoid tumor

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Sternomastoid tumor

Ischemic contracture of a segment of sternomastoid muscle.

Due to trauma at birth infraction and edema.

Later on the lump disappear and the abnormal segment becomes

fibrotic and contracted, leading to torticollis.

Attempts to turn the head straight may cause pain or distress.

Most often located in the inferior to the middle third of the

sternocleidomastoid muscle.

Treatment:

Physiotherapy is recommended to achieve full range of motion.

Some patients have small areas of residual fibrosis.

Surgery is reserved for patients in whom torticollis is present for

more than one year, or if craniofacial asymmetry develops.
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50 year old female presents with a pulsatile,

compressible mass that refills rapidly on the
release of pressure, and can be moved from side
to side but not up and down. Diagnosis?

Carotid body tumor

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VII
.

Carotid body tumor

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Carotid body tumors

Rare tumor of the chemoreceptor tissue in the carotid body.

Usually benign, but can occasionally be malignant (3%).

Appear 40-60 years of age.

The common presentation is a painless slowly growing

lump.

Found in the upper part of the anterior triangle.

Size: 2-3cm to 10 cm in diameter.

Non tender solid, hard mass.

Moves from side to side but not vertically.

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Pulsatile; the common carotid artery can be felt below the

mass, and the external carotid artery may pass over its
superficial surface.
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Investigations:

1. Carotid angiogram to demonstrate the carotid bifurcation.

2. MRI & CT
Biopsy and FNA are contraindicated.

Treatment:
o. Surgical resection for small tumors in young patients.
o. Irradiation or close observation in elderly (surgery is best
avoided in elderly due to its serious complication).
Possible complication of the surgery:
1. Postoperative hemorrhage or late stroke
2. Superior laryngeal nerve injury.
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VIII
.

Pharyngeal pouch

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Pharyngeal pouch

It is a diverticulum of themucosaof thepharynx, just above

thecricopharyngeal muscle.

In middle and old age.

Most patients have symptoms but no abnormal physical signs.

Associated with halitosis, recurrent sore throat, regurgitation

with bouts of coughing and choking, and may cause dysphagia.

The swelling my change in size and often disappears.

Pressure on it causes gurgling sounds and regurgitation.

Mostly theres no palpable swelling, but when appears it is behind

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the sternomastoid muscle, below the level of thyroid cartilage.

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