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 a persistent neck mass

    • Cancer should be definitively ruled out

    • Metastasis from squamous cell carcinoma (SCC) arising within the mouth, pharynx, larynx, or upper esophagus should be suspected

    • Risk factors for SCC include smoking and HPV exposure

• 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 cyst

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

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

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

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

• Thyroglossal duct cyst

  • Most common at age < 20

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

INFECTIOUS AND INFLAMMATORY MASSES

• Reactive cervical lymphadenopathy

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

• Tuberculous and nontuberculous mycobacterial lymphadenitis

  • Uncommon in the United States unless there are specific risk factors for exposure

  • 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, hearing loss, dysesthesias, dysgeusia, or other cranial neuropathies are most common

  • Headache, pain, and cervical lymphadenopathy may occur

  • In patients with cranial neuropathies, ask about risk factors for Lyme disease

  • 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, such as nasopharynx, tonsils, tongue base, and larynx

• Complete head and neck examination is indicated, but often imaging and examination under anesthesia are necessary to detect the primary lesion

• 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 ...