Neck Masses

Neck masses may be due to congenital disorders, infection, or neoplastic lesions. With careful attention to the history and physical examination and selected imaging tests, the physician can arrive at a correct diagnosis.

The patient's age may give a clue to the diagnosis (IabJe.235-7). Neck masses in children represent benign conditions in 90 percent of cases. 42 Neck masses in infants and children commonly include branchial cleft abnormalities, thyroglossal duct cysts, lymphangiomas, hemangiomas, or benign lymphadenopathy. 43 Branchial cysts are round, smooth, and movable, but they are not tender unless they become infected. They are located along the anterior border of the lower sternocleidomastoid muscle (Fig 2.3.5.-7.). In contrast, thyroglossal duct cysts are found in a subhyoid position, either midline or just to the left of midline ( Fig 235-8).

These cysts commonly enlarge after an upper respiratory illness. Lymphangiomas are most commonly found in the lateral cervical region along the jugular chain of lymphatics as a result of sequestration of lymphatic channels and failure to communicate with the internal jugular system. Sixty-five percent of these soft, painless, compressible lymphangiomas are present at birth, and 90 percent are clinically detectable by the end of the second year of life. 44 Large lesions may result in airway and feeding problems. Hemangiomas are congenital vascular malformations that on physical

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TABLE 235-7 Neck Masses by Age

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FIG. 235-7. Lateral neck mass in an adolescent demonstrates an infected branchial cleft cyst. It can be found anatomically along the sternocleidomastoid muscle.

examination are soft, mobile, and frequently have a bluish hue. They undergo a proliferative phase soon after birth, followed by an involutional phase, which is usually complete by age 2 to 3. Almost 90 percent of hemangiomas resolve spontaneously.45 General lymphadenopathy is also common in infants and children and usually is infectious in origin.46

Neck masses in adolescents and young adults represent either infection or tumor. Significant cervical lymphadenopathy, malaise, and pharyngitis are the symptom complex for mononucleosis. A single, large, inflamed anterolateral neck mass in this age group that develops after an upper respiratory infection suggests a branchial cleft cyst. Young adults with multiple, rubbery low-neck masses, night sweats, fever, and malaise may have Hodgkin disease or lymphoma.

In adults, 80 percent of neck masses are neoplastic.47 The most common cause of a unilateral neck mass in a middle-aged person with a history of tobacco use is squamous cell carcinoma of the upper aerodigestive tract metastatic to the cervical lymph nodes. Other common neoplasms that present in the neck include tumors of the parotid, submandibular, and minor salivary glands, and Hodgkin and non-Hodgkin lymphomas. Neoplastic lymph nodes usually feel firm, and, although initially mobile, they become fixed to surrounding structures as the cancer invades their capsules. Infectious neck masses can be seen in adults, but these nodes can be differentiated from their malignant counterparts by their soft and sometimes fluctuant appearance. Untreated suppurative lymphadenopathy can lead to deep neck infections and should be treated aggressively.

Other common neck masses seen in all age groups include prominent normal structures, such as the pulsatile carotid bulb or the hard transverse process of the first cervical vertebra.45 Carotid aneurysm, while uncommon, should be suspected if a patient has an expanding neck mass or a history of cervical trauma. Thyroid masses are common. Diffuse nodular thyroid enlargement that is present for many years suggests a simple goiter, whereas a solitary thyroid nodule, although usually benign, may represent thyroid cancer. Epidermal and dermal inclusion cysts are very superficial and result from recurrent cutaneous inflammation.

In addition to age, the history often helps to limit the differential diagnosis. Infectious processes usually develop over hours to days and have associated pain, redness, warmth, and fever. Patients often have a preceding upper respiratory tract or dental infection. Infected congenital cysts may have enlarged on earlier occasions and resolved with antibiotics. Submandibular gland infections (sialadenitis) often wax and wane, are exacerbated by eating, and may cause a foul taste in the mouth as the gland decompresses. Hodgkin disease and lymphomas are associated with night sweats, malaise, itching, and/or fever. Neoplastic disease usually occurs in patients with a history of heavy smoking and alcohol abuse. Such patients often present with dysphagia, otalgia, dyspnea, voice change, or weight loss.

The head and neck examination should include thorough visualization of the ears, nose, oral cavity, oropharynx, nasopharynx, hypopharynx, and larynx. Factors critical in the neck examination include mass consistency and location, as described above. A variety of laboratory studies may prove useful. A heterophil antibody test may reveal mononucleosis in a young patient with pharyngitis and cervical lymphadenopathy. Serologic tests for HIV infection may help in the evaluation of an at-risk patient with multiple enlarged cervical lymph nodes. Intradermal antigen testing for tuberculosis and a control substance, thyroid function tests, and a complete blood cell count with differential counts can each provide useful data in appropriate situations. Several imaging studies can yield helpful information. Chest radiographs may show a primary lung carcinoma or findings consistent with tuberculosis or lymphoma. CT can delineate cervical anatomic relationships and reveal such pathologic conditions as primary aerodigestive tract cancer.

All patients with neck masses must be assessed for airway patency and protection. Patients with any airway concerns, such as stridor or difficulty breathing, or patients with signs of infection, should be evaluated immediately by an otolaryngologist. All other patients may be referred on an outpatient basis.

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