Neck mass

Background

• Common complaint seen in primary care medicine
• Important to recognize acutely life threatening etiologies, treatable disease, and potential for malignancy

Clinical Features

• Anatomy helpful in determining etiology
  • Anterior and posterior cervical triangles divided by SCM
• Associated symptoms based on etiology:
  • • Pain
    • Skin changes
    • Stridor
    • Hoarseness
    • Fever
    • URI symptoms
    • Weight loss/night sweats
• Important to distinguish chronicity

Differential Diagnosis

• Acute
  • Reactive lymphadenopathy- most common
    • Viral URI
    • EBV
    • CMV
    • Strep/staph
    • HIV
    • Toxoplasmosis
    • Bartonella henselae- kitten or flea exposure
    • Tuberculosis
  • Descending infections from oral cavity
    • Ludwig's angina
  • Sialoadenitis (can also be chronic)
  • Trauma-related
    • Hematoma
    • Pseudoaneurysm or AV fistula

• Subacute (weeks to months)
  • Cancer
    • HPV-related squamous cell carcinoma
    • Upper aerodigestive tract squamous cell carcinoma
    • Metastatic disease
    • Lymphoma
    • Parotid tumors
  • Systemic diseases
    • Amyloidosis
    • Sarcoidosis
    • Sjögren syndrome

• Chronic
  • Thyroid nodules or cancer
  • Goiters
    • Graves' disease
    • Hashimoto thyroiditis
    • Iodine deficiency
    • Lithium use
    • Toxic multinodular
  • Congenital cysts
    • Branchial cleft cyst
    • Thyroglossal duct cyst- 2nd most common benign neck mass
    • Dermoid cyst
  • Carotid body tumor
  • Glomus jugulare or vagale tumor
  • Laryngocele
  • Lipoma/liposarcoma
  • Parathyroid cysts or cancer

Evaluation

• Assess for chronicity, associated symptoms, exposures (cats, undercook meat)
• Physical Examination
  • Benign reactive lymph nodes
    • Mobile, firm, and mildly tender
    • Clinical diagnosis
  • Lymphadenitis/suppurative disease
    • Painful, erythema, possibly fluctuant
    • Clinical diagnosis
    • CT imaging if concerns for deep space infection: trismus, torticollis, stridor, drooling
  • Extrapulmonary form of Mycobacterium tuberculosis (cervical adenopathy)
    • Multiple bilateral lymph nodes
    • Fixed, firm, non-tender, located typically in posterior triangle
  • Cystic masses
    • Soft, mobile, ballotable
    • Thyroglossal duct cyst: midline, adjacent to hyoid, rises with swallowing
    • Brachial cleft cyst: lateral, mandibular angle anterior to SCM
    • Dermoid cyst: submental triangle
  • Malignant lesions
    • Hard, non-tender, and possible immobile
• Sialoadenitis
  • Tenderness to affected salivary gland and pus at the duct orifice
    • Parotid gland- stensen duct
    • Submandibular gland- wharton duct
  • CT or US only if diagnosis is unclear

Management

• • Reactive lymphadenopathy: see specific diagnosis
    • Typically self resolving, supportive only except if related to bacterial disease
  • Lymphadenitis
    • Trial antibiotics with either first-generation cephalosporins, amoxicillin/clavulanate (Augmentin), or clindamycin
  • Suppurative lymphadenitis/abscess
    • Head and neck consultation may be necessary for drainage
  • Sialoadenitis
    • Sialogogues, gentle massage, express gland through duct

Disposition

• Most commonly outpatient treatment either with trial antibiotics or supportive care only if inflammatory/infectious related
• Inpatient admission reserved for severe infections, surgical drainage, or concerns for airway compromise

Follow up important to ensure appropriate resolution and further need for advanced imaging or biopsy

References

• <Haynes J, Arnold KR, Aguirre-Oskins C, and Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91(10):698-706./>
• <Kentab OY, Qureshi N. Chapter 118. Neck Masses in Children. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381590. Accessed August 11, 2016./>