This document discusses the anatomy of the neck and common masses that can occur in the neck region. It describes the landmarks of the neck and triangles. The most common neck masses in pediatric patients are benign, while in adults 80% are non-thyroid masses. The causes of neck masses vary by age. Evaluation involves a thorough examination and diagnostic tests like imaging, biopsy, and bloodwork. Fine needle aspiration biopsy is a standard first step to characterize neck masses. Common pathologies include lymphadenopathy, thyroid masses, salivary gland tumors, and lipomas.

2. Musaddiq Hussain Bangash

3. Prominent landmarks
 Hyoid bone
 Thyroid cartilage (men)
 Cricoid cartilage (women)
 Trachea
 Sternocleidomastoid muscle

4.  Triangles of the neck
 Anterior
 Anterior border of the SCM, midline, lower border of the mandible
 Subdivisions: inferior carotid, superior carotid, submandibular, submental
 Posterior
 Posterior border of SCM, clavicle, anterior border of trapezius
 Subdivisions: subclavian, occipital

7.  In Pediatric age group: 90% benign.
 50% out of which may be congenital.
 In adult population: 80% non-thyroid masses.
(Rule of 80)

9.  <20 years…. Congenital or Inflammatory
 20-40 years…. Inflammatory or Lymphoma
 >40 years… Metastatic

10.  DURATION:
 Acute
 Chronic
 Mode of onset:
 Progressive/ Non-progressive
 Site
 Painful/Painless
 Associated symptoms
 Personal habits
 Previous irradiation or surgery

11.  Site of swelling
 Size
 Number
 Shape
 Surface
 Margins
 Colour
 Overlying skin

12.  Temperature
 Tenderness
 Surface
 Smooth
 Irregular
 Lobulated
 Consistency
 Solid
 soft
 Firm
 Hard
 Rubbery

13.  Mobility
 Fluctuation
 Transillumination
 Pulsation
 Relation to surrounding structures

14.  Blood:
 CBC
 ESR
 TFT
 CRP
 Imaging:
 Computed tomography (CT)
 Magnetic resonance imaging (MRI)
 Ultrasonography
 Radionucleotide scanning
 PET scan

15.  Cytology
 FNAB
 Tissue:
 Incisional/ Excisional Biopsy

16. Fine Needle Aspiration Biopsy (FNAB)
 Standard of care
 Indications
 Not obvious abscess
 Persists following antibiotics
 No contraindications

17.  Ultrasonography
 Inexpensive
 Easily available
 Non expensive
 Useful for solid versus cystic (congenital cyst vs. lymph node/glandular tumor)

18.  Uses Fluorine labelled deoxyglucose
 Used for:
 Evaluation of Regional LN
 Detect distant metastasis
 Synchronous primary lesion

19.  Thyroid Masses
 Lymphoma
 Salivary Tumors
 Lipoma

20.  A leading cause of anterior neck masses
 Children
 Most common neoplastic condition
 Male predominance
 Greater chance of malignancy
 Adults
 Mostly benign
 Female predominance

21.  Lymph node metastatic
 15% of papillary carcinomas
 40% with malignant nodules
 Histologically in >90% (microscopic)
 FNAB is standard of care
 Decreases number of patients with surgery
 Repeat negative aspiration in 1 month

23.  More common in pediatric & young adults
 80% of children with Hodgkin’s have neck mass
 Signs and symptoms
 Mass only, fever, hepatosplenomegaly, diffuse adenopathy
 FNAB - 1st line; open biopsy if suggestive
 CT scans (H&N, chest, abdomen) & bone marrow biopsy

24.  Any preauricular enlarging mass or at the angle of the mandible is suspicious
 Benign - asymptomatic
 Metastatic - rapid growth, skin fixation or cranial nerve palsies
 Open excisional biopsy preferred

25.  FNAB
 Reduces number of patients with surgery by 1/3
 Distinguishes intra-glandular lymph nodes, localized sialadenitis, benign cysts
 Accuracy >90% (better for benign)
 Sensitivity - 90%; Specificity - 80%
 May facilitate surgical planning or patient counseling
 Prepare for total parotidectomy & nerve sacrifice in unknown primaries

26.  Over age 35 usually
 Ill-defined, soft, mobile subcutaneous masses of variable sizes
 Excised only when infected or also for cosmetic reasons

27.  Very common
 Marked tenderness, torticollis, trismus, and dysphagia
 Systemic signs of infection
 Initial treatment - directed antibiotics
 Close follow up

28.  Failure of antibiotics necessitates biopsy after complete head and neck work-up
 FNAB indications
 Progressively enlarging nodes
 Solitary, asymmetric nodal mass
 Supraclavicular mass
 Persistent nodes without infectious signs

29.  Develop over weeks and months
 Minimal systemic complaints or findings
 Firm glands, fixation and injection of skin
 Common etiologies
 Typical Mycobacterium tuberculosis (adults)
 Atypical Mycobacterium tuberculosis (children)
 Cat-scratch fever (Bartonella henselae) (children)
 Actinomycosis, Sarcoidosis

30.  Atypical TB
 Anterior triangle lymph nodes
 Induration and pain
 Usually responds to complete surgical excision
 Cat-scratch fever
 Preauricular or submandibular lymph nodes
 Spontaneous resolution 1-2 months
 Typical TB (rarely seen, posterior nodes)