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 ...