Discuss the differential diagnosis of midline neck masses? Discuss the differential diagnosis of lateral neck masses and lumps? What specific question you would ask in history to elicit the diagnosis? Discuss about management (investigations and treatment plan) for midline neck masses? Discuss about management (investigations and treatment plan) for lateral neck masses? Assuming that this patient presents with a history of weight loss, night sweats and chronic cough, how would you proceed with diagnosis, management and treatment in this patient? Neck masses are common in adults and can occur for many reasons. You may develop a neck mass due to a viral or bacterial infection. Ear or sinus infection, dental infection, strep throat, mumps, or a goiter may cause a neck mass. Clinically neck masses can be divided into: Those in the midline Those in the lateral aspect of triangles of neck which can be further divided according to triangles of neck

1. NECK MASSES/LUMPS
DR AWAIS IRSHAD

2. CBL 18
A 27-year-old male, comes to the OPD with complains of a neck
lump in front of the neck slightly on the left side. This has been
increasing steadily in size for the past 4 to 5 months.
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3. Learning Objectives
1. Discuss the differential diagnosis of midline neck masses?
2. Discuss the differential diagnosis of lateral neck masses and lumps?
3. What specific question you would ask in history to elicit the diagnosis?
4. Discuss about management (investigations and treatment plan) for midline neck
masses?
5. Discuss about management (investigations and treatment plan) for lateral neck
masses?
6. Assuming that this patient presents with a history of weight loss, night sweats and
chronic cough, how would you proceed with diagnosis, management and treatment
in this patient?
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4. Neck Mass
Neck masses are common in adults and can occur for many reasons. You may develop
a neck mass due to a viral or bacterial infection.
Ear or sinus infection, dental infection, strep throat, mumps, or a goiter may cause a
neck mass.
Clinically neck masses can be divided into:
1. Those in the midline
2. Those in the lateral aspect of triangles of neck which can be further divided according to
triangles of neck
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5. Triangles of Neck
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6. Midline neck masses
1. Thyroglossal duct cyst.
2. Sublingual dermoid cyst.
3. Enlargement of sub mental, pretracheal and prelaryngeal.
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7. Thyroglossal Duct Cyst
The thyroglossal duct cyst is the most common congenital anomaly of the central portion of the
neck.
Tract of thyroid tissue along the pathway of embryologic migration of the thyroid gland from the
base of the tongue to the neck.
Due to its attachment with foreamen cecum at base of tongue, it moves on protrusion of
tongue.
This cyst can occur anywhere along the pathway of thyroid duct.
Rarely carcinoma may develop.
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8. Diagnosis
CT/MRI neck should always be done to rule out cyst
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9. Treatment
Complete surgical excision (SISTRUNK’S OPERATION) is done, including hyoid bone and core of
tongue tissue
Simple excision without removal of tract leads to recurrence.
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10. Sublingual Dermoid Cyst
It presents as midline submental swelling but does not move on protrusion of tongue as it is not
attached to foramen caecum.
Treatment is surgical excision.
Midline dermoid is also seen just above suprasternal notch
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11. Enlargement of Nodes
There are 2 to 8 submental nodes situated in submental triangle between platysma and mylohyoid
muscle.
When enlarged, draining areas should be ruled out for malignancy or infections.
Pre-tracheal and Pre-laryngeal nodes drain larynx and trachea, thyroid isthmus and anteromedial
aspect of lobes.
In case of enlargement of nodes, draining areas should be examined.
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12. Lateral neck masses
1. Branchial cyst
2. Branchial sinus or fistula
3. Plunging ranula
4. Carotid body tumor
5. Para pharyngeal tumors
6. Cystic hygroma
7. Tubercular lymph nodes
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13. Branchial cyst
Common in second decade of life but can occur at any age.
Cyst present as swelling in upper part of neck anterior to sternocleidomastoid muscle.
Mass is smooth, round, fluctuant, nontender and nontransilluminant.
Anomalies of second branchial arch are most common, it may be associated with sinus of
fistula.
When both internal and external openings are present it is called fistula.
Treatment option is surgical excision along with tract, if present.
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14. Plunging ranula
It is a pseudo cyst caused by extravasation of mucus from obstruction to sublingual salivary
glands.
It is present as an isolated swelling in submandibular area.
Sometimes it coexists with ranula in floor of mouth.
Treatment option is total excision along with sublingual salivary gland.
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15. Carotid Body Tumor
Arises from chemoreceptor cells in carotid body, hence called chemodectoma.
Mostly presents after 40 years, history of neck mass extend into several years.
It is painless swelling which is pulsatile, bruit can be heard.
It moves from side to side but not vertically.
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16. Diagnosis
Contrast-enhanced CT and MRI are diagnostic and show extent of tumor.
MRI angiography shows splaying of ECA and ICA (Lyre’s sign)
Some tumors secrete catecholamine, so serum level should be estimated
Fine-needle aspiration cytology (FNAC) or biopsy is contraindicated
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17. Treatment
Surgical removal when is patient is below 50 years and surgically fit, or when tumor extends to
oropharynx causing difficulty in speech, swallowing or breathing.
Radiotherapy is also effective and used in older patients, those unfit for surgery.
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18. Cystic Hygroma
Also called lymphangioma/ cavernous lymphangioma, occurs most commonly in posterior
triangle of neck.
Arises from obstruction or sequestration of jugular lymph sac.
Seen in infancy or early childhood.
Seen in supraclavicular region or may extent to other regions.
Hygroma is soft, cystic, multilocular and partially compressible.
May cause stridor, respiratory difficulty or feeding problems.
if inflamed, becomes painful and increases in size.
Treatment option is surgical excision with preservation of vascular and neural structures.
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19. Tubercular Lymph Nodes
Mass due to tubercular lymph nodes is common, any node group can be involved (single,
multiple or matted).
It may become adherent to skin and underlying structures.
DIAGNOSIS is made by FNAC or lymph node biopsy which reveals granulomatous lesion.
Sometimes acid fast bacilli can be demonstrated.
X ray chest, skin test and work-up for nodal involvement should be done.
TREATMENT consists of initial 2 months course of four drugs( Rifampin, isoniazid,
pyrazinamide and ethambutol) followed by a 4 months course.
Surgical excision done when drug therapy fails.
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20. Metastatic Lymph Nodes
Any lymph node group can be involved depending on primary malignancy.
Upper cervical lymph nodes are commonly involved.
Nasopharyngeal malignancies spread to accessory chain of nodes in posterior triangle.
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21. Lymphomas
Both Hodgkin and non Hodgkin lymphomas may present with cervical lymphadenopathy.
May cause:
◦ Dysphagia
◦ Serous Otitis Media
◦ Respiratory obstruction
In such cases other lymph nodes should also be examined
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22. Cervical Rib
Occasionally an extra rib may arise from the 7th cervical vertebrae and end anteriorly by
attaching to the 1st rib.
This rib may produce a bony hard lump in the supraclavicular region.
Most often seen on the right but may be present on the left bilaterally.
May complain:
◦ Numbness of hand and forearm( If brachial plexus is compressed).
◦ Coldness and claudication of hand( due to compression of subclavian artery).
◦ Mural thrombi may also develop.
No treatment if asymptomatic.
May require surgical excision.
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23. PRESENTATION TITLE 23

24. Sternomastoid Tumor
Mostly seen in new borns due to birth trauma.
May cause torticollosis.
Face is turned to the opposite side but head is tilted on the ipsilateral shoulder.
Can be palpated.
Asymmetry of face may develop.
Treatment involves exercises in early stages.
Surgery may be required if persistent.
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25. THANK YOU