this presentation discusses how to approach to the neck mass and important DDx according to the site and age of onset with clinical points about important etiologies

1. An approach to the
neck masses
BY:
HARDI H. QADER
KIRKUK UNIVERSITY COLLEGE OF MEDICINE

2.  Mass: a lump or an aggregation of coherent material (soft tissue
mass)
 Lump: an irregularly shaped mass or piece (breast lump)
 Swelling: an abnormal enlargement of a part of body, typically as
a result of an accumulation of fluid
 Cyst: a swelling consisting of collection of fluid in the sac which is
lined by epithelium or endothelium

3. Anatomy
 The neck is the transitional area between the base of the
cranium superiorly and the clavicles inferiorly.
 The neck joins the head to the trunk and limbs, serving as
a major conduit for structures passing between them.

4. Anatomic landmarks:
Anteriorly: the neck starts from lower border of mandible to the upper border of
the sternum (suprasternal notch) and clavicles.

5. Posteriorly: from external occipital protuberance to the
spinous process of C7

6. Anatomy of the neck by triangles

9. Anterior triangle more subdivided:

11. Posterior triangle more subdivided:

13. Surface Anatomy

14. Anatomy of the Lymph nodes of the neck

15. Surface Anatomy

16. Patient presented with neck lump, swelling or
mass, what is your work up?

17. History

18. History:
1. Age:
 Neck masses in children and young adults are more commonly infl
ammatory than congenital, and rarely neoplastic.
 In adult always there is suspension to be neoplastic.

19. 2. Location
Medline swellings

20. Lateral swellings

21. 3. Duration
 Inflammatory disorders are usually acute in onset, and resolve within
6 weeks.
 Cervical lymphadenitis is often associated with recent upper
tract infection.
 Congenital masses are often present from birth as small,
masses, which enlarge rapidly after mild upper respiratory tract
infection.
 Metastatic carcinoma tends to have a short history of progressive
enlargement.
 Transient post-prandial swelling in the submandibular or parotid area
suggests salivary gland duct stenosis that may lead to obstruction.
 Bilateral diffuse tender parotid enlargement is most commonly mumps
in children and sialosis in adults.

22. 4. Discharge
 Suggest infection mostly complicated congenital
pathologies due to fistula or sinus formation with supper
added infection (Abscess)

23. 5. Others
 Family Hx: TB
 Social Hx: smoking, alcohol, and history of travel and contact

24. Examination

25. Physical examination
1. General examination (JACOL + Vital signs)
2. Full head and neck examination
 The oral cavity and nasopharyngeal
 Mucosal surfaces, is helpful, especially when suspecting
 Palpate the thyroid
 The lumps relation to muscles, trachea, and hyoid bone!
 The location, mobility and consistency of a neck mass can often
it within a general aetiological group – congenital,
nodal/inflammatory, vascular, salivary or neoplastic.

27. Do not forget to chick the abdomen !!!!

28.  Congenital masses are generally soft, smooth and mobile, may be
tender when infected.
 Inflammatory adenopathy is tender, mobile mass
 Chronic inflammatory masses and lymphomas are often non-
tender and rubbery and may be either mobile or feel like matted
adenopathy.
 In older age groups, the submandibular and parotid glands become
ptotic and mimic neck lumps, and can cause concern to patients.

29.  Features rise suspicion of malignancy:
1. voice change,
2. odynophagia,
3. dysphagia,
4. haemoptysis
5. previous radiation, especially with thyroid tumours.
6. oral lesions, recent trauma, globus sensation,
7. referred ear pain, muffled or decreased hearing
8. constitutional symptoms (e.g. night sweats, anorexia, weight loss),
9. unilateral nasal discharge or epistaxis,
10. family history of cancer and previous tumours

30. Diagnostic tools

31. Diagnostic studies
1. Investigations:
I. Full blood count
II. Erythrocyte sedimentation rate (ESR).
III. Throat swab: occasionally helpful, but must be sent immediately in the proper medium.
IV. Viral serology: Epstein–Barr virus, cytomegalovirus and toxoplasmosis.
V. Thyroid function tests ultrasound in all cases of thyroid enlargement.
2. Images:
I. Ultrasonography is useful in differentiating solid from cystic masses.
II. Chest X-ray in smokers with persistent neck lump.
III. CT scan and MRI to determine the extent of the masses
3. Fine needle aspiration biopsy (FNAB) is helpful for the diagnosis of neck masses and any
neck lump that is not an obvious abscess and persists following antibiotic therapy.
 A negative result may require a repeat FNAB, ultrasound-guided FNAB or even an open
biopsy.

32. Treatment is differ according to the diagnosis

33. Characteristics of non-malignant neck lumps
1. Cystic hygroma (Lymphangiomas)
 It is a congenital lesion usually present within the
first year of life.(post. Triangle)
 Usually remain unchanged into adulthood
 Is soft, cystic, multilocular, partially compressible
and brilliantly transilluminant. and may present
with pressure effects.
 CT or MRI may help define the extent of the
neoplasm
 Treatment of lymphangiomas includes injection
with picibanil or excision for easily accessible
lesions or those affecting vital functions.

34. 2. Haemangiomas
 Often appear bluish and are
compressible.
 CT or MRI may help define the extent
of the neoplasm, especially
intrathoracic.
 Treatment : (depend on site, size and
severity) most often resolve
spontaneously within the first decade.
 surgical treatment is reserved for
lesions with rapid growth involving
vital structures, which fail medical
therapy (cs, laser or oral propranolol
in infantile type).

35. 3. Branchial cleft cysts
 Reminant of branchial cleft (2nd).
 Most commonly occur in the second or third
decades!
 Pain +/- (severe throbbing pain)
 Usually presents as a smooth, fluctuant
nontender (tender) , nontransluminal mass
mobile forwards and downwards, underlying the
anterior border of the sternomastoid muscle.
 Branchial fistula or sinus !
 Primary treatment is with control of infection by
antibiotics, followed by surgical excision.

36. 4. Thyroglossal duct cyst
 This is a common congenital midline neck
mass.
 Sometimes at the lateral edge of the
thyroid cartilage.
 Pain and tenderness +/-
 Can be moved transversally but can not
be moved vertically
 Elevates on protrusion of the tongue.
 Treatment is with initial control of infection
with antibiotics, followed by surgical
excision including the mid-portion of the
body of the hyoid bone (Sistrunk’s
procedure). Occasionally, these lesions
become infected and resolve, or persist
following surgery as a thyroglossal fistula.

37. 5. Lipoma
 Lipomas are the most common benign soft tissue neoplasm in
the neck. They are poorly defined, soft masses usually
after the fourth decade.
 They are usually asymptomatic, soft to feel and deep to the
 FNAC or MRI Scan can confirm the diagnosis.
 Surgery is indicated when the lump is increasing in size,
cosmesis, or when there is doubt about the accuracy of
diagnosis.

38. 6. Sebaceous cysts
 These are common masses occurring
often in older people but can occur at any
age.
 They are slow growing, but sometimes
fluctuant and painful when infected.
 Diagnosis is made clinically; the skin
overlying the mass is adherent and a
punctum is often identified.
 Excisional biopsy confirms the diagnosis.

39. 7. Cervical lymphadenopathy
 Acute lymphadenitis
 tender swelling
 Antibiotic trial, Less acute inflammatory
nodes generally regress in size over 2–6
weeks.
 If the lesion does not respond!
 biopsy

40. 8. TB cervical lymphadenitis
 Upper and middle deep cervical LN
 Onset: gradually
 Pain: +/-
 Systemic symptoms unusual in young (occurs with
 Abscess (painful, increase size, and skin discoloration)
 Mass: indistinct, firm, matted, fluctuate!
 Temperature! (Cold abscess)

41. • Treatment with anti TB (6-9 months)
Rifampicin
Ethambutol
INH
Pyrazinamide

42. 9. Carotid body tumour
 Rare tumour of chemoreceptors (40-60 years).
 Slow-growing painless some time pulsating
lump may be bilateral.
 Side to side movement
 Symptoms of transient cerebral ischemia!
 Potato tumours (hard, non tender)
 Palpation may induce vasovagal attack
 Biopsy is contraindicated MRI angiography is
the investigation of choice.
 Surgical removal is based on patient factors
presenting symptoms.

44. 10. Pharyngeal pouch
 diverticulum of the pharynx through the gap
between the horizontal fibres of the
cricopharyngeus muscle below and the
lowermost oblique fibres of the inferior
constrictor muscle above.
 history of halitosis regurgitation of froth and
food. There is no bile or acid taste to it.
 Pressure on the swelling causes gurgling
sounds and regurgitation
 Treatment: cricopharyngeal myotomy

45. 11. Ludwing’s angina
 Rare but serious connective tissue infection of the
floor of the mouth
 Mostly due to dental infections
 Sings of inflammation present
 Treatment: drainage of pus + antibiotic to cover
aerobes with anaerobes

46. 12. Thyroid masses
 Thyroid neoplasms are a common cause
of anterior compartment neck masses in
all age groups, with a female
predominance, and are mostly benign.
 Fine needle aspiration of thyroid masses
has become the standard of care and
ultrasound may show whether the mass
cystic.
 Unsatisfactory aspirates should be
repeated, and negative aspirates should
be followed up with a repeat FNAC and
examination in 3 months’ time.

47. Characteristics of malignant neck lumps
1. LYMPHOMAS
 Painless lump, nontender smooth and discrete
 Slow growing
 Patient Presented with malaise, wt. loss, pallor.
 Fever, rigor and hepatosplenomegaly
 Mediastinal mass (SVC syndrome)
 Abdomen pressure on IVC may cause bi lateral leg oedma
 other lymph nodes in the axilla, groin and abdomen should
examined
 Treatment: according to stage (radiosensitive)

48. 2. METASTATIC LYMPH NODES
 Upper cervical lymph nodes (upper aerodigestive tract).
 Accessory chain of nodes in the posterior triangle (Nasopharyngeal
malignancies). In many cases
 (Occult primary) most common sites are tonsil, base of tongue,
nasopharynx and pyriform sinus.
 Virchow's LN (toisier’s sign) abd. And thoracic malignancies
 Painless, nontender, and hard masses
 Work up: Search for primary and deal with it

49. To be a successful surgeon
you need the eyes of a hawk,
the heart of a lion, and a
hand of a lady
Thank you