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For further information, see CMDT Part 8-34: Diseases Presenting as Neck Masses

Key Features

Essentials of Diagnosis

  • Rapid growth and tenderness suggest an inflammatory process

  • Firm, painless, and slowly enlarging masses are often neoplastic

General Considerations

  • Neck masses in young adults

    • Most neck masses are benign

      • Branchial cleft cyst

      • Thyroglossal duct cyst

      • Reactive lymphadenitis

    • However, malignancy should always be considered

      • Lymphoma

      • Metastatic thyroid carcinoma

  • Lymphadenopathy is common in HIV-positive individuals, but a growing or dominant mass may well represent lymphoma

  • Neck masses in adults over 40

    • Cancer is the most common cause of persistent neck mass

    • A metastasis from squamous cell carcinoma (SCC) arising within the mouth, pharynx, larynx, or upper esophagus should be suspected, especially if there is a history of tobacco or significant alcohol use

  • An enlarged node unassociated with an obvious infection should be further evaluated, especially if the patient has a history of smoking or alcohol use or a history of cancer

Clinical Findings

Symptoms and Signs

CONGENITAL LESIONS

  • Branchial cleft cysts

    • Soft cystic mass on anterior border of sternocleidomastoid muscle; present with sudden swelling or infection at age 10–30

    • First branchial cleft cysts present just below ear; fistulous connection with external auditory canal floor may occur

    • Second branchial cleft cysts more common; may communicate with tonsillar fossa

    • Third branchial cleft cysts rare; may communicate with piriform sinus; present low in the neck

  • Thyroglossal duct cysts

    • Most common at age < 20

    • Midline neck mass, often just below hyoid bone, that moves on swallowing

INFECTIOUS AND INFLAMMATORY MASSES

  • Reactive cervical lymphadenopathy

    • Tender enlargement of neck nodes caused by pharynx, salivary gland, and scalp or HIV infection

  • Tuberculous and nontuberculous mycobacterial lymphadenitis

    • Single or matted nodes

    • Can drain externally (scrofula)

  • Lyme disease

    • May have protean manifestations

    • Over 75% of patients have symptoms involving the head and neck

    • Facial paralysis, dysesthesias, dysgeusia, or other cranial neuropathies are most common

    • Headache, pain, and cervical lymphadenopathy may occur

    • See Lyme Disease

TUMOR METASTASES

  • In older adults, 80% of firm, persistent, enlarging neck masses are metastases

  • Most metastases arise from SCC of upper aerodigestive tract

  • Complete head and neck examination indicated

  • Other than thyroid carcinoma, nonsquamous cell metastases to neck are infrequent

  • Except for lung and breast tumors, non-head and neck tumors seldom metastasize to middle or upper neck

  • Except for renal cell carcinoma, infradiaphragmatic tumors rarely metastasize to neck

LYMPHOMA

  • About 10% present in head and neck

  • A growing concern in AIDS patients

  • Multiple rubbery nodes, especially in young adults

Differential Diagnosis

  • Reactive lymphadenopathy

  • Lymphoma

  • Skin abscess

  • Parotitis

  • Goiter

  • Thyroiditis, thyroid carcinoma

  • Branchial cleft or thyroglossal duct cyst

  • SCC of upper aerodigestive tract

  • Sarcoidosis

  • Autoimmune adenopathy

  • Kikuchi disease

    ...

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