NECK MASS

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NECK MASS

• Assessment of a neck mass
• M. Hosseini M.D.
• Head Neck Surgeon
• Rasool Akram Hspital
• Iran University

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Question

• 1- What structure is the neck mass arising form ?
• 2- Is it a lymph node ?
• 3- Is the mass arising from a normally occurring
• structure (thyroid never vessel muscle)
  ?
• 4- Abnormal structure (larngocele brachial
• cleft cystic hygroma) ?
• 5- Is the mass soft , fluctuant mobile fixed
  ?
• 6- Palsato
• 7- Bruit
• 8- Superficial deep
• 9- Is it attached to the skin ?
• 10 - Tender

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• - Duration
• - Growth rate ( M gt B )
• - Location (Congenital Developmental)

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Risk Factor

• Tobacco
• Alcohol
• Leukoplakia
• Erthroplakia
• Poor Hygiene
• Submucosal fibrosis
• Local inflammation due to trauma
• Trauma

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• - Deletion of chromosomes 3p 18q
• - Amplification of int 2 and bcl -1
• - Mutation of p 53
• - Overexpression of transforming
• growth factor (TGF a)
• - Epidermal growth factor receptor (EGF1)

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I. Muscle fibrous tissue

• A. Congenital / developmental fibromatosis
  colli
• B. Inflammatory myositis
• C. Neoplastic
• 1. Benign rhabdomyoma
• 2. Aggressive fibromatoses
• 3. Malignant rhabdomyosarcoma
• D. Miscellaneous
• 1. Benign masseter muscle hypertrophy
• 2. Compensatory muscle hypertrophy (often
  seen after
• R . N . D)

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II. Lymphatic reticuloendothelialsystems

• A. Congenital cystic hygroma , hamartoma
• B. Inflammatory lymphadenitis
• 1. Viral
• a. Cat scratch disease
• b. Infectious monoucleosis
• 2. Bacterial
• a. Routine ( strept. Staph. )
• b. Syphilis
• c. T.B.
• d. Actinomycosis
• 3. Fungal
• a. Histoplasmosis
• b. Blastomycosis
• 4. Parasitic
• a. Toxoplasmosis
• b. Leishmaniasis

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II. Lymphatic reticuloendothelialsystems

• C. Neoplastic (Primary metastatic lymphnode)
• 1. Sarcomas
• a. Lymphomas (Hodgkins non- hodgkin)
• b. Soft part sarcoma
• c. Leukemias
• 2. Carcionomas ( all metastatic)
• a. Squamous cell
• b. Melanoma
• c. Thyroid malig.
• d. Salivary gland malig.
• D. Miscellaneous
• Drug reaction (Phenytoin)

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III. Salivary glands

• A. Congenital cysts
• B. Inflammatory
• 1. Acute viral sialoadenitis (mumps)
• 2. Acute bacterial sialoadenitis
• 3. Chronic sialoadenitis
• C. Enlargement secondary to systemic disease
  obesity , alcoholism, malnutrition

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III. Salivary glands

• D. Neoplastic
• 1. Benign hemangioma, mixed tumor,
  warthins
• 2. Malignant nucoepidermoid ca. , adenoid
  cystic ca.
• E. Obstructive enlargement
• 1. Sialolithiasis
• 2. Ductal stricture
• F. Miscellaneous enlargements of salivary glands
• 1. Sjogrens synd.
• 2. Drug reaction (iodine)

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IV. Vascular system

• A. Developmental / degenerative / traumatic
• 1. Aneurysm
• 2. Arteriovenous malf.
• 3. Tortuous arteries
• 4. Hematoma
• B. Neoplastic
• 1. Hemangiomas
• 2. Angiosarcomas
• 3. Hemangiopericytoma
• 4. Carotid body tumor

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V. Nervous system

• A. Benign
• 1. Neurofibroma
• 2. Neuroma
• 3. Neurilemmoma (schwannoma)
• 4. Paragangliomas (carotid body, vagal body,
  
• glomus jugulare tumors)
• B. Malignant (rare)
• 1. Neurogenous sar.
• 2. Neuroepithelioma
• 3. Malig. schwannoma

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VI. Thyroid gland

• A. Congenital / developmental cysts
• B. Inflammatory
• 1. Acute thyroiditis
• 2. Subacute (de Quervains)
• 3. Chronic thyroiditis
• a. Lymphocytic (Hashimotos)
• b. Fibrous/ ligneous (Riedels)

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VI. Thyroid gland

• C. Neoplastic
• 1. Benign adenomas
• 2. Malignant
• a. Papillary car.
• b. Follicular car.
• c. Medullary car.
• d. Poorly diff. car.
• D. Miscellaneous
• 1. Diffuse colloid goiter
• 2. Diffuse goiter with hyperthyroidism
• 3. Nodular goiter

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VII. Miscellaneous soft tissue neop.

• A. Benign
• 1. Lipoma
• 2. Myxoma
• 3. Hibernoma
• B. Malignant
• 1. Synovial cell sarc.
• 2. Liposarcoma

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VIII. Larynx, pharynx, deep neckstructures

• A. Developmental
• 1. Malformed laryngeal cartilage
• 2. External laryngocele
• 3. Branchial cleft abnormalities
• B. Inflammatory
• 1. Deep neck infection / abscess
• 2. Osteomyelitis of cervical spine
• C. Neoplastic
• 1. Car. Of larynx pharynx
• 2. Chordoma of larynx
• 3. Neoplasm of cervical spine

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IX. Other assorted lesions

• A. Bezolds (mastoid) abscess
• B. Cholesteatoma from mastoid
• C. Thymoma
• D. Epidermoid inclusion cyst

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AGE ( YEARS )
0 - 15
Inflammatory
Neoplastic Adenitis
Lymphoma
(AT/PT) Bacterial (AT/PT)
Thyroid Carcinoma (M)
Viral (AT/PT)
Sarcoma (AT/PT)
Granlomatous (PT/AT)
Congenital
Branchial cyst (AT)
Thyroglossal cyst (M)
Vascular Lesion (PT) Dermoid
(M)



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AGE ( YEARS )
16 - 40
Inflammatory
Neoplastic Adenitis
Lymphoma
(AT/PT) Viral (AT/PT)
Thyroid Carcinoma (M)
Bacterial (AT/PT)
Salivary (AT) Granlomatous
(PT/AT) Metastatic (AT/PT)
Aids (AT/PT)
Vascular (AT/PT) Congenital
Neurogenic
(AT) Branchial cyst
(AT) Thyroglossal cyst (M)
Dermoid (M)



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AGE ( YEARS )
40
Neoplastic Metastatic carcinoma
(AT/PT) Thyroid carcinoma
(M) Inflammatory Adenitis
Viral (AT/PT)
Bacterial (AT/PT)
Granlomatous (PT/AT) Aids
(AT/PT) Congenital


Branchial cyst (AT)
Thyroglossal cyst (M)
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Chronic infection

• 1- T.B
• 2- Fungal
• 3- Syphilis
• 4- Cat scratch fever
• 5- Aids
• 6- Sarcoidosis
• 7- Mononucleosis

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Infection inflammation ( Fever Pain
Tenderness ) T.B Sarcoidosis Fungal
infection Dental problems Trauma to H.
N. ?Cancer ( Skin lesion Head Neck Tumor
) Night sweats ( lymphoma ) Exposure to the sun (
Skin cancer ) Smoking or excessive alcohol
consumption ( S.C.C of the fead Neck )
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Nasal obstruction Nasal bleeding Otalgia Odynophag
ia Dyspahgia Hoarseness


Malignancy of upper aerodigestive tract
Exposure to low dose therapeutic radiation (
risk factor for thyroid Cancer)

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1- Preferred method 2- Cystic form
solid 3- Often diagnose malignancy 4-
Standard for making treatment decisions
in patiets with thyroid nodules 5-
Bleeding from it make problem for CT MRI
6- Fna is not valuable in
Nodul of thyroid with History of Radiation,
Lymphoma.
Biopsy
FNA
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Thyroid Nodules

• - Childern , young men , pregnant women ,
• radiation , family history of the thyroid
  cancer .

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Imaging Studies
Ultrasonography A - Solid Cystic B -
Congenital developmental ( cyst ) C - Vascular
, thyroid parathyroid abnormality
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CT
A - Solid Cystic B- Mass is within or outside
a gland or nodal chain C- Small tongue base ,
tonsillar mass that have minimal mucosal
component
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MRI
T2 Weighted gadolinium enhanced scans
is Useful for invasion of soft tissue by tumor.
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Arteriography

• A- evaluating vascular lesions
• B- fixation of tumor to the carotid
• C- vascularity of mass
• D- specific blood supply

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Thyroglossal duct cysts

• 1- 70 of all congenital abnormalities of the
  neck
• 2- First decade of life
• 3- Midline
• 4- Move side to side but not up to down
• 5- 1 contain cancer ( papillary ca-S.c.c. )

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Branchial cleft cysts

• 1- Five branchial arches four clefts
• 2- Internal tract or opening is situated at
  pharyngeal
• groove such as tonsil ( second Arch ) or
  piriform
• Sinus ( Third fourth arches )
• 3- The Second arch is the most common
• 4- Anterior border of S.C.M
• 5- Most are diagnosed in the first two decades of
  life
• ( any age )
• 6- Lateral neck ( smooth , painless , slowly
  enlarging
• mass )

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Cystic Hygroma
( Lymphangiomas )

• 1- Second year of life
• 2- 80 in P.T.
• 3- Floor of the mouth- supraclavicular, root of
• the neck , angle of the jaw may involved
• parotid tongue larynx .
• 4-Diffuse , soft , doughy , irregular mass .
• 5- Transilluminated
• 6- Aspiration yields straw colored fluid

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Vascular Malformation
( Hemangiomas )

• - Congenital
• - Bluish purple coloration , increased warmth ,
  
• compressibility , bruit , thrill most of them
  
• resolve spontaneously

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Salivary gland Tumors (B)

• - Complete submandibular resection
• superficial parotidectomy

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PATIENT AGE ( YEARS )
16 - 40
FREQUENCY OF DISEASE GROUPINGS
INFLAMMATORY
CONGENITAL /
DEVELOPMENTAL
NEOPLASTIC
MALIGNANT
BENIGN
TRAUMATIC LOCATION
Anterior triangle
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PATIENT AGE ( YEARS )
40
FREQUENCY OF DISEASE GROUPINGS
NEOPLASTIC
MALIGNANT
BENIGN
INFLAMMATORY LOCATION
Posterior triangle
CONGENITAL / DEVELOPMENTAL
TRAUMATIC
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PATIENT AGE ( YEARS )
0 - 15
FREQUENCY OF DISEASE GROUPINGS
INFLAMMATORY
CONGENITAL /
DEVELOPMENTAL
NEOPLASTIC
MALIGNANT
BENIGN
TRAUMATIC LOCATION
Midline and anterior neck
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PATIENT AGE ( YEARS )
16 - 40
CAUSATIVE DISEASES BY LOCATION
Congenital /
Developmental Thymic
cyst
Sialadenopathy
Parotid
Submandibular
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INFLAMMATORY
Adenitis Sialadenitis
Viral
Parotid Bacterial
Submandibular
Granulomatus
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Neoplastic
Metastatic
Lymphoma Upper jugular (II)
Primary vascular Oropharynx
Carotid body Oral
cavity
Glomus Oral cavity
Hemangioma Nasal sinus Face Mid
jugular (III) Hypopharynx Larynx Traumatic False
aneurysm
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PATIENT AGE ( YEARS )
0 - 15
CAUSATIVE DISEASES BY LOCATION
Congenital /
Developmental
Thyroglossal duct cyst
Dermoid
Laryngocele
Inflammatory Adenitis
Neoplastic
Thyroid
Lymphoma
Traumatic
Sternocleidomastoid
Hematoma / fibroma
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INFLAMMATORY
Adenitis Sialadenitis
Viral
Parotid Bacterial
Submandibular
Granulomatus
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PATIENT AGE ( YEARS )
40
CAUSATIVE DISEASES BY LOCATION
Congenital /
Developmental
Lymphangiom Neoplastic
Inflammatory
Lymphoma
Adenitis
Metastatic (V)
Bacterial
Superior Viral


Lung


Gastrointestinal


Genitourinary

Gyneocologic
Nasopharynx
SCALP
Supraclavicular
Breast
Granulomatous
Traumatic
Neuroma