Slide 3

Approach

 Our approach involves an understanding of 2 basic factors that in combination will allow a
diagnosis to be made.
 An understanding of these factors is critical. They are: • anatomy — major structures of the
neck and lymph nodes of the neck • pathology that may arise in the above structures, i.e.
the differential diagnosis.
 Assessing the location of a neck mass is essential as it provides clues to the aetiology.
 If one can first identify the structure that is enlarged and second match that with the
pathologies that may occur within that structure, then most of the problem is solved, and
appropriate investigations can be performed

Slide 5

History

 A careful history can provide important clues to the diagnosis of a neck mass.
 Duration of symptoms is one of the most important points in the history.
 Benign and congenital neck masses are often present for an extended duration —
sometimes, but not always, since birth.
 Inflammatory neck masses are usually acute in onset and resolve within several weeks.
 Malignant neck masses, as in metastatic carcinoma to cervical lymph nodes, tend to have a
history of progressive enlargement
 More than 80% of these tumours are associated with tobacco and alcohol use in persons
over 40 years of age
 Cervical lymphadenitis, the most common cause of neck masses, is often associated with
upper respiratory tract infections.
 Dental problems, and insect bites should be sought.
 Further features of malignancy include voice change, odynophagia, dysphagia, haemoptysis
and previous radiation, especially with thyroid tumours, oral lesions, globus sensation,
referred ear pain, muffled or decreased hearing,unilateral nasal discharge or epistaxis,
family history of cancer and previous tumours.

Slide 6

Anatomy

 Assessing the location of a neck mass is essential as it provides clues to the aetiology

This may be divided into 2 parts, namely the major structures and the lymph nodes.

Major structures

 The major structures are located largely in the anterior triangles. The borders of the anterior
triangles are the inferior border of the mandible, the sternocleidomastoid muscle and the
midline.
 The borders of the posterior triangle are the sternocleidomastoid muscle, the trapezius
muscle and the clavicle.
 The major structures that can be palpated in the midline, within the anterior triangles and
from superior to inferior, are the hyoid bone (C3), the thyroid cartilage (C4-C5) with its
 notch (the ‘Adam’s apple’), the cricothyroid membrane, the cricoid cartilage(C6) and the
trachea.
 The thyroid gland is usually palpable in the midline below the thyroid cartilage.
 The carotid bulb can be palpated near the anterior border of the sternocleidomastoid
muscle at the level of the hyoid bone
 Carotid arteries are pulsatile and can be quite prominent if atherosclerotic disease is
present. The sternocleidomastoid muscles should be palpated along their entirety, with
careful attention given to deep jugular lymph nodes.

 The parotid glands are located in the preauricular area on each side in the lateral neck lies
over the angle of the mandible, in front of and below the ear
 The submandibular glands are located below the body of the mandible within a triangle
bounded by the sternocleidomastoid muscle, the posterior belly of the digastric muscle, and
the body of the mandible. In older patients, these glands may become ptotic and appear
more prominent.

Lymph nodes

 The location of cervical lymph nodes can be divided into six levels.The level of the lymph
nodes can be predictive as to the source of the problem.
 Level I includes submandibular and submental nodes.
 Levels II, III and IV encompass lymph nodes along the internal jugular vein, deep to the
sternocleidomastoid muscle in the upper, middle and lower thirds of the neck respectively.
 Level V contains the nodes in the posterior triangle. These are commonly enlarged in viral
infections, e.g. mononucleosis.
 Level VI lies between the carotid sheaths in the anterior triangle and contains the
prelaryngeal and pretracheal node

Slide 8

Examination

 Examination should include the mass itself, the rest of the neck, the skin of the head and
neck and the ENT system (ears, oral cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx and the larynx).
 First question to ask is whether the mass is a lymph node or part of another neck structure
 The size, consistency, tenderness and mobility of the mass provide diagnostic clues.

Acute inflammatory masses tend to be soft, tender and mobile.

Chronic inflammatory masses are often non-tender and rubbery and either mobile
or matted.

Congenital masses are usually soft, mobile and non-tender unless infected.

Vascular masses may be pulsatile or have a bruit.

Malignant masses may be hard, nontender and fixed.

 Palpation of parotid, submandibular and thyroid glands

 Examine the skin and scalp of the head and neck should be examined for primary cutaneous
tumours. Recent bite marks/scratches may indicate catscratch disease.
  Otoscopy- The ear may reveal serous otitis media associated with a nasopharyngeal
carcinoma or a a sinus or fistula associated with a branchial anomaly
 Nasal examination may reveal a unilateral nasal mass or discharge suspicious of a neoplasm.
 Oral cavity -The mucosa of the oral cavity/oropharynx may reveal a primary malignancy. In
particular, examine the lateral border of the tongue, floor of mouth, soft palate/tonsil
complex, because the great majority of oral cancers arise from these areas. Furthermore,
palpate the base of the tongue to exclude occult lesions.
 A unilateral, asymmetrically enlarged tonsil may suggest a neoplasm. Alternatively, a
normal sized tonsil pushed across towards the midli.ne by a parapharyngeal mass may cause
a similar appearance. A parapharyngeal space mass may also present as a neck mass.
 Dentition should be examined as an infective cause of cervical lymphadenitis. Examination
of the submandibular area is assisted by bimanual palpation.
 Assessment of the mass with swallowing is important as movement from swallowing
suggests a lesion in the thyroid gland or a thyroglossal cyst.The latter also elevates with
tongue protrusion and is located in the midline around the level of the hyoid bone and may
be associated with a cutaneous fistula as well.3 Branchial cysts are located anywhere along
the anterior border of the sternocleidomastoid muscle,3most commonly at the junction of
the upper and middle thirds

Classification of neck masses

Congenital

Cystic hygromas are typically noticed and diagnosed before aged two years* , presenting as soft
painless fluctuant masses that transilluminate. They can be associated with congenital
conditions (e.g. Turners syndrome) and can grow large enough to cause airway obstruction or
dysphagia.

Carotid body tumours (also known as a carotid paragangliomas) are benign neuroendocrine
tumours that arise from the paraganglion cells of the carotid body - pulsatile painless neck lump,
often with a bruit present on auscultation*. Carotid paragangliomas are slow growing, but can
become large enough to compress surrounding cranial nerves, leading to palsies.

Branchial cysts, which usually present in early adulthood, occur anywhere along the anterior border
of the sternocleidomastoid muscle and often seem to appear rapidly following an upper respirator
tract infection. Lymphangiomas present in early infancy and can often be transilluminated.

The most common is the thyroglossal duct cyst that usually presents in the midline and elevates
with swallowing or tongue protrusion. This latter factor distinguishes it from a congenital dermoid
cyst.

Inflammatory

Lymphadenitis

Bacterial — streptococcal and staphylococcal infections; mycobacterial infections — tuberculosis

and atypical mycobacteria; lymphadenitis secondary to dental infection and tonsillitis;unusual
disorders — cat-scratch disease

• Viral — Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), other viruses
causing URTIs, HIV
 Infectious mononucleosis usually presents with acute pharyngitis, cervical adenopathy, and
an elevated Epstein-Barr virus titer.

• Parasitic — toxoplasmosis

• fungal — coccidiomycosis

• Salivary gland inflammation

Sialadenitis (parotid, submandibular and sublingual) due to obstruction, e.g. calculus, or

infections, e.g. mumps

• Thyroiditis.

Benign Masses
Lipomas, hemangiomas, neuromas, and fibromas are benign neoplasms that occur in the neck. They
are all characterized by slow growth and lack of invasion. Lipomas are soft masses that are isodense
with a fat signal on magnetic resonance imaging. Neuromas may arise from nerves in the neck and
rarely present with sensory or motor deficits. M

Malignancy

Thyroid cancer, salivary gland cancer, lymphomas, and sarcomas are examples of primary
malignancies.

Secondary: Most common origin of these metastases is squamous cell carcinoma of the upper
aerodigestive tract

Kimura's disease is an uncommon chronic inflammatory condition involving subcutaneous tissue.

The etiology is unknown. The disease presents as a tumor-like lesion with a predilection for the head
and neck region.

Castleman's disease is a benign lympho-proliferative disorder that most frequently involves the
mediastinal lymph nodes. It typically presents in the head and neck as cervical adenopathy of
unknown etiology. Multiple biopsies showing florid lymphoid hyperplasia are frequently required to
establish the diagnosis.