Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-34: Diseases Presenting as Neck Masses + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ An MRI or PET scan before open biopsy may yield valuable information about a possible presumed primary site or another site for fine-needle aspiration (FNA) biopsy +++ Diagnostic Procedures ++ Common indications for FNA biopsy of a node include persistence or continued enlargement, particularly if an obvious primary tumor is not obvious on physical examination +++ TUBERCULOUS AND NONTUBERCULOUS MYCOBACTERIAL LYMPHADENITIS ++ FNA is usually the best initial diagnostic approach: send specimens for cytology, smear for acid-fast bacilli, culture and sensitivity, as indicated +++ TUMOR METASTASES ++ Examination under anesthesia with direct laryngoscopy, esophagoscopy, or bronchoscopy is usually required to fully evaluate the tumor and exclude second primaries +++ LYMPHOMA ++ FNA may be diagnostic, but open biopsy is often required + Treatment Download Section PDF Listen +++ +++ Medications +++ TUBERCULOUS AND NONTUBERCULOUS MYCOBACTERIAL LYMPHADENITIS ++ See Table 9–15 for current recommended treatment of tuberculous lymphadenopathy For atypical (nontuberculous) lymphadenopathy, treatment depends on sensitivity results of culture, but antibiotics likely to be useful include 6 months of isoniazid and rifampin and, for at least the first 2 months, ethambutol—all in standard dosages ++Table Graphic Jump LocationTable 9–15.Recommended dosages for the initial treatment of tuberculosis.1View Table||Download (.pdf) Table 9–15. Recommended dosages for the initial treatment of tuberculosis.1 Medication Daily2 Cost3/Day Twice a Week2 Cost3/Wk Three Times a Week2 Cost3/Wk Isoniazid 5 mg/kg Max: 300 mg/dose $0.31/300 mg 15 mg/kg Max: 900 mg/dose $1.86 15 mg/kg Max: 900 mg/dose $2.79 Rifampin 10 mg/kg Max: 600 mg/dose $2.66/600 mg 10 mg/kg Max: 600 mg/dose $5.32 10 mg/kg Max: 600 mg/dose $7.98 Pyrazinamide 18.2–26.3 mg/kg Max: 2 g/dose $13.95/2 g Weight-based dosing: see references below1 — Weight-based dosing: see references below1 — Ethambutol 14.5–21.1 mg/kg Max: 1.6 g/dose $3.74/1.6 g Weight-based dosing: see references below1 — Weight-based dosing: see references below1 — 1Data from Nahid P et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of drug-susceptible tuberculosis. Clin Infect Dis. 2016 Oct 1;63(7):e147–95.2All dosing regimens should be used with directly observed therapy.3Average wholesale price (AWP, for AB-rated generic when available) for quantity listed. Source: IBM Micromedex. Red Book (electronic version). IBM Watson Health, Greenwood Village, CO, USA. Available at https://www.micromedexsolutions.com/ (cited March 25, 2020). AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions.Also available at www.cdc.gov/tb/topic/treatment/guidelinehighlights.htm. +++ Surgery +++ BRANCHIAL CLEFT CYSTS ++ To prevent recurrent infection and possible carcinoma, branchial cleft cysts should be completely excised, along with their fistulous tracts +++ THYROGLOSSAL DUCT CYSTS ++ Surgical excision is recommended to prevent recurrent infection +++ REACTIVE CERVICAL LYMPHADENOPATHY ++ Except for the occasional node that suppurates and requires incision and drainage, treatment is directed against the underlying infection + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Prognosis is that of the underlying pathology +++ When to Refer ++ When the diagnosis is in question or for specialized treatment, particularly for a malignancy + References Download Section PDF Listen +++ + +Białek EJ et al. Mistakes in ultrasound diagnosis of superficial lymph nodes. J Ultrason. 2017 Mar;17(68):59–65. [PubMed: 28439430] + +Celenk F et al. Predictive factors for malignancy in patients with persistent cervical lymphadenopathy. Eur Arch Otorhinolaryngol. 2016 Jan;273(1):251–6. [PubMed: 26187739] + +Derks LS et al. Surgery versus endoscopic cauterization in patients with third or fourth branchial pouch sinuses: a systematic review. Laryngoscope. 2016 Jan;126(1):212–7. [PubMed: 26372400] + +de Tristan J et al. Thyroglossal duct cysts: 20 years' experience (1992–2011). Eur Arch Otorhinolaryngol. 2015 Sep;272(9):2513–9. [PubMed: 25135577] + +Green B et al. Current surgical management of metastases in the neck from mucosal squamous cell carcinoma of the head and neck. Br J Oral Maxillofac Surg. 2016 Feb;54(2):135–40. [PubMed: 26432197] + +Ha EJ et al. Efficacy and safety of ethanol ablation for branchial cleft cysts. AJNR Am J Neuroradiol. 2017 Dec;38(12):2351–6. [PubMed: 28970243] + +Herd MK et al. Lymphoma presenting in the neck: current concepts in diagnosis. Br J Oral Maxillofac Surg. 2012 Jun;50(4):309–13. [PubMed: 21546141] + +Jin LX et al. Surgery for lymph node metastases of medullary thyroid carcinoma: a review. Cancer. 2016 Feb 1;122(3):358–66. [PubMed: 26539937] + +Liang L et al. A meta-analysis on selective versus comprehensive neck dissection in oral squamous cell carcinoma patients with clinically node-positive neck. Oral Oncol. 2015 Dec;51(12):1076–81. [PubMed: 26500065] + +Patigaroo SA et al. Thyroglossal duct cysts: a clinicosurgical experience. Indian J Otolaryngol Head Neck Surg. 2017 Mar;69(1):102–7. [PubMed: 28239589] + +Ross J et al. Thyroglossal duct cyst surgery: a ten-year single institution experience. Int J Pediatr Otorhinolaryngol. 2017 Oct;101:132–6. [PubMed: 28964283] + +Zhou J et al. Fine needle aspiration cytology for lymph nodes: a three-year study. Br J Biomed Sci. 2016;73(1):28–31. [PubMed: 27182674]