NECK MASSES


DEFINITION

The differential diagnosis of a lump in the neck.
N.b. An isolated neck mass in a patient >40yo should be considered malignant until proven otherwise.

Risk factors
For malignancy in adults include
- smoking and alcohol
- sun exposure
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AETIOLOGY

May be congenital and acquired
If acquired, may be infective, inflammatory, neoplastic (benign, malignant; primary, secondary), trauma, degenerative.

Classification
Swellings superficial to the deep investing fascia are non-specific to the neck.
Swellings deep to the fascia may be specific.
Deep swellings may be midline or lateral.

Seive

Skin / Subcutaneous
Sebaceous cysts.
Lipomas.
Fibromas

Salivary
Calculi; sialolithiasis
Sublingual gland obstruction
Parotitis / other glanditis.
Neoplasm
Plunging ranula

Thyroid
Thyroglossal duct cyst
- midline, elevates with tongue protrusion.
Neoplasm
Goitre

Lymph Node
Acute infection
- eg viral or abscess deep.
- jugular nodes commonly involved in viral adenitis (including EBV, HIV).
- bacterial commonly staph, strep
Chronic eg TB / syphilis
Rarely other infections
- e.g. protozoa; toxoplasmosis
- e.g. fungi: histoplasmosis
Sarcoidosis
Lymphoma
- fleshy, matted, large, rubbery.
Metastasis
- eg thyroid, parathyroid, nasopharynx, tonsils, larynx, pharynx.
- melanoma, SCC, salivary gland tumours, carcinoids
- 25% from upper GI primary.

Muscle
Torticollis
SCM tumours

Vessel
Vascular malformations
Carotid body tumours
Aneurisms / ectasia

Congenital Structures
Branchial cysts.
- usually anterior to upper 1/3 of SCM.
Dermoid cysts.
Cervical ribs.
Cystic hygroma.
- infants, base of neck, transilluminate brilliantly.

Confusing lesions
'ptosis' of the submandibular gland may be mistaken for a mass in older people.
Enlarged nodes may represent reactive nodes.


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BIOLOGICAL BEHAVIOUR
As per cause.

Consider:

1. Location
Either descriptive (e.g. jugulodigastric, posterior cervical)
Or by neck-level
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MANIFESTATIONS
A painless single enlarged node is a malignancy until proven otherwise.
Other symptoms vary by cause.

Symptoms
Enquire as to cause.
- thorough systems review of all relevant structures.
Systemic features, e.g. fevers, sweats, weight loss, fatigue.

Signs
Site, size, shape, surface, edges, consistency, pulsatility, mobility, fluctuance, pain, tenderness, lymph nodes.
- accurate site localization with knowledge of neck anatomy
- measure mass size accurately.

Key Points
Thyroid swellings move upwards.
Ventral lumps attached to the hyoid (eg thyroglossal cysts) move up on swallowing and tongue protrusion.
Multiple lumps almost always lymph nodes.
Examine the full head and neck, including oral cavity.
Special attention to the aerodigestive mucosa, especially lymphoid region of nasopharynx, base of tongue and oropharynx
Palpation includes bimanual exam of floor of mouth and neck to identify abnormalities deep to normal mucosa.
Neurological exam of cranial nerves required.
Examine dentition
Reactive lymphadenopathy and primary, unusual or atypical infections.

Perform:
Flexible Fibreoptic Laryngoscopy
- especially for patients with suspicious features / risk factors
Fundoscopy
Auroscopy
Nasopharyngoscopy
Bronchoscopy
Gastroscopy
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INVESTIGATIONS

As per suspicion.

FNA / biopsy.
Allows rapid cytopathological diagnosis.
Must be done before any empiric therapy attempted.
- unless possibility of being vascular
Method:
- LA
- enter with slight negative pressure with a 20mL syringe and a 21g needle
- hold mass in thumb and forefinger, use multiple angled passes under negative suction; 3-4 aspirates
- reduce suction and remove syringe prior to removing the needle from skin
- discard any blood
- squirt onto a slide, then that slide is smeared with a second slide.
- promptly fix with ethanol or formalin before cells dessicate
--> best if a cytopathologist is on site to check specimen adequacy
- sensitivity and specificity approach 90%, and are highest for thyroid masses and solid carcinomas.
If nodes are cystic, need to biopsy the cyst wall with USS guidance

Imaging
USS first - accessible and no rads.
- cystic or not?
USS / CT often useful.
- contrast enhanced CT with fine slices of 3-5mm
MRI useful for soft tissue involvement or iodine allergies.
- may show certain lesions more accurate, e.g. carotid body paraganglionomas
CXR in selected cases
- atypical infections and granulomas.

Role of PET
Used for finding primary sources when endoscopies unhelpful.
Characterize extent of disease when previous known history of head and neck malignancy.
- fusion PET/CT more useful tool; allows for accurate anatomical localization of lesions.
--> accurate for occult cervical mets.
PET inappropriate when primary malignancy diagnosed.
- FNA the lesion

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MANAGEMENT

Broadly dependent on identification and diagnosis.
When infectious inflammatory, tissue diagnosis when ABx fail to treat
When neoplastic, tissue diagnosis essential and thorough search for primary source
- occasionally no identifiable primary; consider PET and MDT review

EUA
Most lesions can be diagnosed in the clinic; in some, EUA is useful
- e.g. if FNA unhelpful and clinical concern
Aids inspection of all mucosal surfaces
Biopsies under controlled settings

Medical Management
If <40, then medical management usually warranted in first instance
Biopsy first in pts >40

Surgical Considerations

1. Many neck lumps are deep to platysma and may involve important structures
- open biopsy under GA preferred

2. Incision lines in transverse relaxed skin tension lines
- should be sufficient to get safe exposure to important structures, e.g. muscles, great vessles, CNs

3. Risks:
- neurovascular injury
- chyle leak
- nerves X, XI, XII at risk, as well as marginal branch of VII and phrenic.
--> VII and XI most commonly injured
Marginal branch of VII courses up from main trunk in parotid to cross mandible and ultimate innervate lower lip depressors
-avoid region of body of mandible to reduce risk to this nerve; incisions two finger-breadths below inferior edge of mandible
CN XI exists in cranial base of jugular foramen
- passes over internal jugular as it travels to trapezius
- identify as it innervates SCM, if anterior border of digastric skeletonized and fascia followed to SCM; n. is deep to posterior belly of digastric.
- alternatively, along posterior of SCM about 2cm superior to Erb's point; intersection of great auricular and posterior border of SCM
--> very superficial course in posterior neck, where easily injured.
--> avoid cutting any structure passing through posterior neck that is greater than 2mm
CN XII passes levels I and II deep in the neck
- descends between IJV and carotid artery before innervating the tongue musculature.
- surrounded by venae conniventes under posterior belly of digastric
--> may be damaged when controlling bleeding from the venae; inadvertently clamped
Thoracic duct lies in lower neck
- deep in inferomedial aspect of left supraclavicular region
- duct runs behind the common carotid and empties into the IJV near its junction with the subclavian vein
- there are also chyle-containing lymphatics in the right neck that should be controlled during dissection
- all tissue between phrenic and vagus should be dissected to avoid a chyle fistula
--> manage chyle leaks with low-fat diet and medium-chain triglicerides supplementation;
--> somatostatin may help to augment closure of a delayed chyle leak
--> rarely, surgical intervention needed

4. Carotid body paraganglionoma
- high risk surgery; tertiary specialist job
- do not biopsy
- CNs at risk.
- usually achievable with subadventitial dissection and without vascular reconstruction.


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Jerome Notes

Neck swellings

Differential diagnosis

Superficial

· Epidermoid cyst

· Lipoma

· Neurofibroma

Deep

Submandibular / digastric triangle

Solid

· Submnandibular gland

— Mumps

— Sialolithiasis

— Tumours

· Lymph nodes

Cystic

· Second branchial cleft cyst

· Sublingual dermoid

· Plunging ranula

· Cystic hygroma

Central

· Thyroglossal cyst

— See above

· Pharyngeal pouch

— See oesophagus

· Laryngocele

— Laryngeal mucosal herniation through thyrohyoid membrane

— Can be reduced

— Returns with coughing

· Subhyoid bursa

· Thyroid isthmus

· Lymph nodes

· Ranula

· Dermoid

Lateral

· Lymph nodes

— Deep cervical

— Jugulodigastric

— Jugolo-omohyoid

· Thyroid

· Salivary gland

— Parotid

· Branchial cysts

· SCM ‘tumour’

— Fibrous mass in SCM ® wry neck

· Carotid body tumour

· Infections

— Actinomycosis

— TB

· Cervical rib

Rule of 80’s

Congenital vs Acquired (80%)

Inflammatory vs Neoplastic (80%)

Benign vs Malignant (80%)

vs 2° (80%)

Below vs Above clavicle (80%)

Ix of neck swellings

FNA

v Assess pulsatility 1st

Solid

· Cell cytology

Cystic

· Aspirate

— Straw coloured cystic hygroma

branchial cyst (usually darker)

— Toothpaste sebaceous

· Cell cytology

— Endothelium cystic hygroma

— Keratin dermoid

— Squamous cells branchial

· Mucin content

· Biochemistry

— Amylase ranula

— Cholesterol branchial

Assessment of lymphadenopathy

DD

· Malignancy

— Skin

— SCC

— Melanoma

— Merkels

— Oral cavity

— Nasopahryngeal

— Salivary gland

— Branchial cyst

— Thyroid

— Chest

— GIT

            — Virchows node

— Breast

— 1° lymphatic

            — lymphoma

            — lymphosarcoma

· Inflammatory

· Non infective

— Amyloidosis

— Sarcoidosis

· Infective

— Acute

— Chronic

            — TB

            — Acintomycosis

            — Toxoplasmosis

            — Cat scratch

— Viral

            — HIV

            — EBV

            — CMV

Indication for Ex Bx

· FNA non diagnostic

— Doesn’t decrease in size over 1/12

— Don’t suspect TB ?

Better to repeat FNA & do acid fast stain & culture

Miscellaneous neck lesions

Cystic Hygroma

· Lymphatic in origin

· Majority present in first 2 yrs

— 50% @ birth

· Failure of development of lymphatic channels

· Neck most common site

· Extensive multiloculated

· Clear straw coloured fluid

· Lined with endothelial cells

Management

· Excision

· Aspiration & injection of fibrin tissue adhesive

Dermoids

Embryology

· Embryonic ectoderm fuses in midline

— Dermoid result of inclusion rest

Clinical

· Young adults

· 2% occur in floor of mouth

· Lined by stratified squamous epi

— Epidermoid cysts only squamous epi

— Dermoids hair sweat galnds and sebaceous galnds

· Contain degenerated keratin

Management

· Excise

Plunging ranula

· Outpouching of sublingual or minor salivary galnd

· Often 2° to blockage of duct

· Plunging ranula descends through or posterior to mylohyoid

· Painless swelling in floor of mouth and neck, bluish

· High amylase and mucin content

· No epithelial lining

· Differentiate from cystic hygroma as no change in size with valsalva, or decrease with pressure

Treatment

· Excision of ranula only

· Marsupilisation

· Excision of ranula and associated gland

— Lowest recurrence rate

— Need to preserve submandibular duct through mucosal flap (Mastery p314)

TB of neck

v aka scrofula

· Often JDG node is involved as Ghon focus with 1° site being tonsil

· Can be due to reactivation of 1° infection

· Node intially mobile then fixed

· Caseation® cold abscess

· May fistulate

· If forms superficial abscess ® collar stud abscess

Carotid body tumours

Tumour types

· Chemoreceptors (chemodectomas) respopnding to blood O2 and CO2 tension

· Paraganglionomas of vagal body or glomus jugular

· Phaeochromocytoma

Aetiology

· Chronic hypoxia ® carotid body hyperplasia

— More common @ high altitude

Clinical

· 10% FH

— 30% of these bilateral ± other paraganglionomas

· 10% malignant

— Staging related to degree of invasion into vascular wall

· 10% symptomatic

— cranial n palsies

H&N 13

· Majority asymptomatic

— Painless lump @ level of hyoid under SCM ± mass in pharynx

— Often pulsatile

Ix

· Duplex USS

· Arteriogram

— Splaying of junction

— Tumour blush

— Can embolise larger tumours

Mx

Surgery

· If >3cm embolisation should be considered followed by surgery in 2-3/7

· Approach as for CEA

· Control all 3 major arteries as for CEA

· Risk of CVA 3%

Radiotherapy

· Infirm

· Distant mets

· Too big to excise

· Recurrence

Natural history

· Slow growing

· If no Rx

— 75% asymptomatic patients develop symps

— 30% die principally due to local invasion

H&N 14