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Hatem Alwagih Neck Mass
Neck Mass Hatem Alwagih
Associate Professor of Surgery
Department of Surgery
Faculty of Medicine
University of Alexandria
Evaluation which leads to the proper treatment and the best outcome
Learning Objectives
1- Describe a systematic method for evaluating patients with neck masses
2- Suggest the appropriate diagnostic studies
3- Discuss differential diagnosis of neck masses
4- Describe the outlines of surgical treatment of neck masses
Classification Neck masses can be originated from: Skin, Endocrine organs, Upper
aerodigestive Tract, Vessels, or Lymph Nodes
They are classified into:
• Congenital
• Acquired
o Inflammatory
o Benign Neoplasm
o Malignant Neoplasm
Evaluation which leads to the proper treatment and the
best outcome follows the following 4 steps: I Appropriate initial assessment
II Role and technique of FNAB
III Appropriate use and interpretation of imaging
IV Management: Importance of specialized multidisciplinary care if malignancy
is suspected
Hatem Alwagih Neck Mass
I Appropriate Initial Assessment
The correct diagnosis of a lump in the neck can often be made with a careful
history and examination. The clinical signs of size, site, shape, consistency,
fixation to skin or deep structures, pulsation, compressibility, transillumination
or the presence of a bruit still remain as important as ever
• Age
• Location
• Risk Factors
• Symptoms
• Head & Neck Exam
Age
Young Adult
• Congenital
• Inflammatory
• Malignant
Age
Adult ( >40)
• Malignant
• Congenital
• Inflammatory
Pediatric
• Inflammatory
• Congenital
• Malignant
Hatem Alwagih Neck Mass
Age & Location: The Adult with a Lateral Neck Mass
Location
Angle of Mandible
• Parotid
Central Compartment
• Thyroid
Lateral Neck
• Lymph Node
Age & Location: The Adult with a Lateral Neck Mass
80% Neoplastic
20% Inflammatoryor Congenital
20% Benign
80% Malignant
20% Primary
80% Metastatic
Neck Mass
“Rule of 80’s”
Hatem Alwagih Neck Mass
Risk Factors
•Sexual Behavior
HPV & HN
• Male predominance Cancer
• Younger patients
• Fewer traditional risk factors
• Sexual behavior as risk factor multiple sexual partners (>6) higher rates of
oro-genital contact with multiple partners
•Sun Exposure
Symptoms of Head and Neck Primary
● Otalgia, unilateral ● Hemoptysis
● Nasal obstruction (snoring) ● Unilateral hearing loss
● Dysphagia ● Epistaxis
● Hoarseness
Symptoms of Lymphoma
● Fever
● Night Sweats
● Weight Loss
Physical Exam What do we need to document?
• Location of the mass in the neck
• Presence/absence of a primary in the head and neck
• Presence/absence of generalized lymphadenopathy
Hatem Alwagih Neck Mass
Physical Exam
Physical Exam
• Location of the mass in the neck
- Triangles
- Levels
III
III
IVV
Physical Exam
• Location of the mass in the neck
- Triangles
- Levels
III
III
IVV
Physical Exam
• Lymph nodes
- oral cavity
- skin
I I
Hatem Alwagih Neck Mass
Physical Exam
• Lymph nodes
- oropharynx
II
Physical Exam
• Lymph nodes
- larynx
- hypopharynx
- thyroid
III
Hatem Alwagih Neck Mass
Physical Exam
• Lymph nodes
-Thyroid
-Below Clavicle
IV
Physical Exam
• Lymph nodes
- nasopharynx
V
Physical Exam
• Presence/absence of a primary in the head and
neck - oral cacvity and oropharynx
Mashberg. Cancer 1973,32:1436-1445
Distribution of
Early Oral Cancer
Hatem Alwagih Neck Mass
Physical Exam
• Presence/absence of a primary in the head and
neck - oropharynx and larynx
Palpation Base of Tongue
Fiberoptic Nasendoscopy
II Role and Technique of FNAB
• Needle size: 25 gauge
• 12-15 Passes should be performed
•Immediate assessment of adequacy by the Pathologist is the rule
FNAB Immunohistochemistry
SCC
Cytokeratin
Positive
Lymphoma
CD45/CD30
Positive
Poorly Differentiated
Malignancy
Hatem Alwagih Neck Mass
Fine Needle
Aspirartion Biopsy
Diagnosis of Lymphadenopathy
• Sensitivity 85-97%
• Specificity 98-100%
• Nondiagnostic 8-16%
• Open Biopsy 22-30%
Role of Open Lymph Node Biopsy
Excisional/Incisional Biopsy may be necessary:
• Sub classification of lymphoma
• Facilitate diagnosis of poorly differentiated carcinoma
• Persistently nondiagnostic FNAB
Hatem Alwagih Neck Mass
III Appropriate use and Interpretation of Imaging
CT
MRI Adults with a lateral neck mass
Assess possible primary
USChildren
Central compartment, all ages
PETMultidisciplinary planning for
select malignant tumours
IV Management: Importance of specialized multidisciplinary care if malignancy is suspected
Hatem Alwagih Neck Mass
Non-malignant neck lumps
1. Cystic hygroma (Lymphangiomas)
• It is a congenital lesion usually present within
the first year of life. (Posterior Triangle)
• Usually remain unchanged into adulthood
• 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
2 Branchial cleft cysts
• Remnant of branchial cleft (2nd)
• Most commonly occur in the second or third
decades
• Pain +/- (severe throbbing pain)
• Usually presents as a smooth, fluctuant non tender
(tender), non transilluminant 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.
Hatem Alwagih Neck Mass
3. Thyroglossal duct cyst
• This is a common congenital midline neck mass
• Sometimes at the lateral edge
• Pain and tenderness +/-
• Can be moved transversally but
• 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 drainage as a
thyroglossal fistula.
4. 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.
• 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.
5. 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.
Hatem Alwagih Neck Mass
6. 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 is warranted
7. TB cervical lymphadenitis
• Upper and middle deep cervical LN
• Onset: gradually
• Pain: +/-
• Systemic symptoms unusual in young
• Abscess (painful, increase size, and skin discoloration )
• Mass: indistinct, firm, matted, fluctuate!
• Temperature!(Cold abscess)
• Treatment with anti TB (6-9 months) Rifampicin Ethambutol INH
Pyrazinamide
Hatem Alwagih Neck Mass
8. Carotid body tumour
• Rare tumour of chemo receptors (40-60 years).
• Slow-growing painless some time pulsating lump
may be bilateral.
• Side to side movement
• Symptoms of transient cerebral ischemia!
• Potato tumors (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 and
presenting symptoms.
9. Pharyngeal pouch
• Diverticulum of the pharynx through the gap
between the horizontal fibers of the
cricopharyngeus muscle below and the
lowermost oblique fibers of the inferior
constrictor muscle above.
• History of froth and acid taste
• Halitosis regurgitation of food. There is no
bile or to it.
• Pressure on the swelling causes gurgling
sounds and regurgitation
• Treatment: cricopharyngeal myotomy
Hatem Alwagih Neck Mass
10. Ludwig'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
11 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.
Characteristics of malignant neck lumps
1. Lymphomas
• Painless lump, non tender 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)
Hatem Alwagih Neck Mass
2. Metastatic Lymph Nodes
• Upper cervical lymph nodes (upper aerodigestive tract).
• Accessory chain of nodes in the posterior triangle (Nasopharyngeal
malignancies).
• (Occult primary) most common sites are tonsil, base of tongue,
nasopharynx and Piriform sinus.
• Virchow's LN (Toisier ’s sign) abdominal and thoracic malignancies
• Painless, non tender, and hard masses
• Work up: Search for primary and deal with it