Neck Masses
67 NECK MASSES
Nathan W. Pearlman M.D.
1. What causes lumps in the neck?
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Enlarged lymph nodes, benign or malignant tumors, congenital abnormalities, and normal anatomy.
2. Can neck masses be part of normal anatomy?
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Yes. In some patients, the neck mass is nothing more than a submaxillary gland or omohyoid muscle that has become prominent with aging and loss of surrounding fat. This finding usually is apparent if the other side of the neck is carefully examined.
3. A 34-year-old man presents with a 2-3-cm mass just below the angle of the mandible. What are the likely causes?
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Nonspecific lymphadenopathy
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Branchial cleft cyst
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Infectious mononucleosis
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Submaxillary or parotid gland tumor
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Intraoral infection
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Lymphoma
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Carotid body tumor
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Metastatic carcinoma
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4. Doesn’t this patient seem awfully young for metastatic cancer?
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Yes, but it still occurs in this age group, particularly thyroid, tongue, and nasopharyngeal cancer.
5. This is a long list. Is there any way to narrow it?
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* Inflammatory nodes and nodes of mononucleosis are mildly tender, relatively soft, bilateral (one side may be more symptomatic than the other) of recent onset. They generally are < 3 cm in diameter, the patient usually reports a history of a systemic illness, and the skin over the tender nodes is normal.
* Lymphadenopathy caused by intraoral infection is also of recent onset but exquisitely painful, indurated, and unilateral; the overlying skin is often erythematous.
* Carotid body tumors may be tender and unilateral but are long standing, more rubbery than infectious nodes, and cannot be separated from the carotid pulse.
* A branchial cleft cyst is unilateral, relatively soft, nontender, and long standing; it also transilluminates.
* Nodes of lymphoma are nontender and have the consistency of the submaxillary gland. They may be unilateral or bilateral and of recent onset or several months' duration. In addition, signs of systemic illness may or may not be present.
* Submaxillary or parotid tumors are rubbery and nontender and occupy the position of the contralateral gland.
* Lymphadenopathy caused by metastatic cancer is hard, nontender, and often larger than 3-4 cm.
* Tuberculosis can mimic all of these conditions.
6. Why not just remove the mass or lymph node and see what it is?
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Open biopsy can unduly complicate further management when it is the initial diagnostic maneuver. If lymphoma or an unusual infection is present but not suspected, the node may be mishandled when sent to the pathology or microbiology departments. If metastatic cancer is the problem, the scar tissue created by the biopsy may be difficult to distinguish from tumor on computed tomography (CT) or magnetic resonance imaging (MRI), leading to inaccurate staging. The scar also may resemble cancer at subsequent surgery, potentially resulting in a larger operation than originally needed. A better choice for histologic diagnosis is fine-needle aspiration (FNA), which is 95% accurate and avoids the problems of open biopsy.
7. A complete head and neck examination shows nothing abnormal, but FNA of the node reveals squamous cancer. What should be done next?
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Examination of mouth, pharynx, larynx, esophagus, and tracheobronchial tree under anesthesia (triple endoscopy) should be done. If nothing is seen, blind biopsy of the nasopharynx, tonsils, base of tongue, and pyriform sinuses should be done at the same sitting.
KEY POINTS: DIFFERENTIAL DIAGNOSIS OF NECK MASSES
1. Enlarged lymph nodes
2. Benign or malignant tumors
3. Congenital abnormalities
4. Normal anatomy (e.g., submaxillary gland or omohyoid muscle that has become prominent with age)
8. Isn’t this a bit much?
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No. The squamous cancer came from somewhere, and the most likely site is somewhere in the region (e.g., mouth, pharynx). In approximately 15% of patients, the primary tumor is detected at triple endoscopy when it cannot be found on office examination, and another 10% of patients are found to have a synchronous second primary tumor elsewhere in the aerodigestive tract.
9. Why not just start with triple endoscopy and skip all the other folderol?
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Examination with the patient awake provides information about tongue and laryngeal function that cannot be obtained when the patient is asleep, and treatment planning depends on such knowledge. In addition, examination under anesthesia may be a blind search because of collapse of the tongue and pharynx, unless directed by findings while the patient is awake.
10. Should CT scan or MRI be used?
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Both modalities may provide information about areas difficult to evaluate by physical examination, such as the base of the skull, and are helpful in staging if cancer is present. However, they do not replace the measures already outlined.
11. We do all that and still can’t find a primary tumor. What now?
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Two options exist. Most surgeons would treat the patient with a functional or modified radical neck dissection and postoperative irradiation to the neck and likely site of the primary tumor. Alternatively, one may proceed with irradiation alone to the neck and likely primary site, with neck dissection at a later date if the enlarged node or nodes persist after treatment.
12. What if the primary tumor never shows up? Does this influence prognosis?
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No. Prognosis is determined by the presence of metastatic neck disease, not by whether a small primary tumor is or is not found.
13. If the mass or enlarged node is in the posterior triangle of the neck, is the work-up still the same?
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Yes. Although most oral or pharyngeal tumors spread first to nodes in the anterior triangle, it is not uncommon for naso- or hypopharyngeal tumors, thyroid cancers, and lymphomas to present as enlarged nodes in the posterior triangle.
14. What if FNA of the node reveals only lymphocytes or shows adenocarcinoma?
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The presence of lymphocytes most likely represents inflammation or lymphoma; however, if the “node” is just below the ear lobe, it may be a Warthin’s tumor (cystadenoma-lymphomatosa) of the parotid. Adenocarcinoma found on FNA usually indicates metastases from thyroid cancer or a primary site below the clavicles, but it may mean salivary gland cancer if the “node” lies high in the anterior triangle. If only lymphocytes are present, excision of the node may be reasonable, as long as it was clearly not in the parotid or submaxillary gland. In the latter case, one should proceed with a parotidectomy or submaxillary gland excision.
15. Lumps in the neck are common, and relatively few patients have cancer. Isn’t this a cost-ineffective approach?
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No. Most patients with lumps in the neck have benign, self-limiting conditions, which should be apparent on the initial history and physical examination. If there is a question, FNA can be done. Only rarely is removal of the mass indicated for diagnosis or treatment.
On the other hand, if neck lumps are routinely excised to facilitate the work-up (or to see what they are), the physician will constantly be surprised by what is found (e.g., metastatic cancer, lymphoma, tuberculosis). The work-up outlined above will then have to be undertaken anyway-and in a field dirtied by the biopsy. Such a course is not cost effective but, in fact, is a waste of time and resources.
References
WEB SITE
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BIBLIOGRAPHY
1. Attie JN, Setzon M, Klein I: Thyroid cancer presenting as an enlarged cervical lymph node. Am J Surg 166:428-430, 1993. Medline Similar articles
2. Lee NK, Byers RM, Abbruzzese JL, Wolfe P: Metastatic adenocarcinoma to the neck from an unknown primary source. Am J Surg 162:306-309, 1991. Medline Similar articles Full article
3. Rice DH, Spiro RH: Metastatic carcinoma of the neck, primary unknown. In Current Concepts in Head and Neck Cancer. Atlanta, American Cancer Society, 1989, pp 126-133. Full article
4. Tarantino DR, McHenry CR, Strickland T, Khiyami A: The role of the fine-needle aspiration biopsy and flow cytometry in the evaluation of persistent neck adenopathy. Am J Surg 176:413-417, 1998. Medline Similar articles Full article
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
