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Neck Masses

Presented by Wan Nabilah
Supervised by Prof. Mohammad Khammash


Anatomy of the neck
(central & lateral)
Central neck includes midline
structures such as the hyoid
bone, thyroid and cricoid
cartilages, the thyroid isthmus
and the trachea

The sternocleidomastoid
muscle divides the lateral
neck into 2 major triangles:


Anatomical regions of the neck


Lymph nodes of the head and neck


Approach to neck
 History
 Physical Examination
 +/- Investigations


previous infection  Family history : malignancy  Social history : smoking. skin changes. night sweats. alimentary or skeletal symptoms  Neoplasm • High spiking fever.History  Age   Mass growth pattern : duration. weight loss. itching  Lymphoma • Loss of appetite & weight. pallor. pulmonary. general malaise  Acute infection  Past medical history : past malignancy. previous irradiotion.size. alcohol. rigors. 6 occupational exposures. painful. other masses  Head & neck symptoms  Review of systems • Fever. travel history) . illicit drug use.

Physical Examination  Inspection • Mass localization. Site Neck masses: site Midline Thyroid Dermoid cyst Thymic cyst Lymphadenopathy Lateral Anterior triangle Posterior triangle Lymphadenopathy Branchial  cyst Lymphadenopathy Cystic hygroma 7 .

tenderness. mobility. cranial nerves…)  Systemic examination (RS & GI) 8 . color • Relation to muscles (muscle contraction) • Relation to trachea (swallowing) • Relation to hyoid bone (tongue is protrusion)  Palpation: temperature. skin. size. edge. ENT. thyroid.• Shape. fluctuation. LNs. surface. pulsation.  Percussion for retrosternal goiter  Auscultation for bruits  Complete Head & Neck Examination (Mouth. consistency.

• CBC. blood culture • EBV. TFT • ESR. • Persistence of a newly discovered neck mass beyond three weeks. CMV serology • Tuberculin skin test … 9 .Investigations  Laboratory studies • When the history or physical examination does not suggest transient reactive lymphadenopathy as the cause of a neck mass.

an aneurysm or a pharyngeal pouch.  Diagnostic studies: • FNAB (inflammatory vs neoplastic masses) o Biopsy should never be used before excluding lesions such as a carotid body tumor. • Core needle biopsy • Excisional or incisional biopsy 10 .Investigations  Imaging studies • Chest X Ray • Contrast CT scan of the neck • US • MRI or PET/CT scanning for follow-up.

Muscular Mass 3.Sebaceous .Cystic Hygroma 1.Dermoid Cyst Acquired Lateral : 1.Lymphadenopathy 2.Branchial Cyst 2.Primary Reticulosis 11Cyst 5.Neoplastic 4.Infectious 3.Cystic Vascular 4.Neck Mass Congenital Midline : 1.Thyroglossal Cyst 2.

Cervical lymphadenopathy Reactive Reactive viral viral lymphadenopathy lymphadenopathy Tuberculous lymphadenitis Metastatic tumors Primary neoplasms 12 .I.

13 . 3. glandular fever. neck. Enlargement of the cervical lymph glands is the commonest cause of a swelling in the neck. cat scratch disease. toxoplasmosis. lymphosarcoma.  The four main causes of cervical lymph gland enlargement are: 1. Primary tumor: lymphoma. TB. chest and abdomen. Reticulosarcoma. 2. Sarcoidosis. Infection: non-specific tonsillitis. Metastatic tumor: from the head. 4.

Diagnosis? Reactive viral lymphadenopathy (tonsillitis) 14 . it was firm.This child presented with a swelling in his neck post upper respiratory tract infection. tender and mobile.

• Mobile  Treatment is usually by treating the underlying cause. • The common presenting symptom is a painful lump just below the angle of the jaw. (Antibiotics…) 15 . • Usually associated with tonsillitis in young children.Reactive viral lymphadenopathy • The upper deep cervical glands are most often affected.

pain (pain if it grows rapidly and necrose). • Usually not tender with normal color. usually with no generalized infection. 16 . • Children. • Gradual onset of a lump in the neck +/.Tuberculous lymphadenitis • Upper deep cervical gland. discrete & between 1-2 cm in diameter. • In early stages the glands are firm. young adults and elderly.

Tuberculous abscess: • The swelling increases in size. anorexia 17 and general malaise. . with discoloration of the overlying skin and normal temperature (cold abscess). • There may be tachycardia. firm mass (matted together). becomes more painful.• As caseation increases and the glands necrose it forms indistinct. fever.

• Small nodules are observed & should be excised if they enlarge.Treatment: • A full course of antituberculous chemotherapy is given. • Tuberculous abscess: drainage (aspiration or incision) + continuation of medical therapy. 18 .

Tuberculous lymphadenitis A chronic tuberculous sinus that has become secondarily infected 19 .

• More common in men.Metastatic tumors • Metastatic deposits of cancer cells are the commonest cause of cervical lymphadenopathy in adults. enlarged lymph glands in the neck. • The patient usually presents with painless hard. 20 . • Most common in ages between 55-65 years.

• The larynx & thyroid drain into the middle & lower cervical glands. (ex. Virchow’s gland/ Troisier's sign). 21 . • An enlarged supraclavicular lymph gland commonly indicates intraabdominal or thoracic disease. The site of the affected glands gives a crude indication of the site of the primary lesion: • Lesions above the hyoid bone drain into the upper deep cervical glands.

they may have local symptoms (sore tongue.  FNAB is the STANDARD of diagnosis for neck masses If you suspect malignancy (90% true diagnosis). or the abdomen (dyspepsia or abdominal pain) + general symptoms of anorexia and weight loss. may be pale or blotchy red (if large enough to stretches or infiltrates the skin). 22 .) • If the primary tumor is in the chest (cough or hemoptysis).. • Tethered to the surrounding structures. • Not tender. • Normal color. so they can usually be moved in transverse direction but not vertically.• Primary cancers in H&N do not cause anorexia and weight loss. variable sizes. hoarse voice. • Stony hard.

• Painless. slowly growing lump in the neck • Usually in the posterior triangle.Primary neoplasms of the lymph glands • The most common is the malignant lymphoma (Hodgkin’s & Non-Hodgkin’s) • Two peak. • General symptoms (malaise. 23 . itching. weight loss. fever and rigors)  Treated by radiotherapy and chemotherapy. • Solid & rubbery in consistence. usually associated with pruritus. • Males are more often affected. 15-35 years and above 50 years. not tender. pallor.

in a child and an elderly. 24 . male.Lymphoma in the posterior triangle.

II . Branchial cyst 25 .

Branchial cyst • Its is a remnant of a 2nd branchial cleft • Lines by squamous epithelium.  Presentation : Asymptomatic Painful if become infected 26 . contains thick and turbid fluid full of cholesterol crystal • Present since birth. Can present in 40s & 50s • Males = females. but majority present between ages 15-25 years.

27 . Branchial fistula (sinus) Ultrasound Fine Needle Aspiration  Treatment: Controlling infection if present. then surgical excision. mostly soft Ovoid in shape. Exam : Fluctuant swelling. if so reconsider your diagnosis (TB abscess or papillary carcinoma of the thyroid). Infection  Investigation: 2. may transilluminate.  Complications: 1. 5-10 cm The local deep cervical lymph nodes should not be enlarged.

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Thyroglossal cyst 30 .III.

31 .Thyroglossal cyst • It is a fibrous cyst that forms from a persistent thyroglossal duct. • Most common congenital neck mass • It can occur anywhere between the base of the tongue and the isthmus of the thyroid gland • They are commonly found in two sites: between the isthmus of the thyroid gland and the hyoid bone. and just above the hyoid bone.

5 to 5 cm in diameter. tenderness and increase in size (if infected). Thyroglossal sinus 3.• Any age.  Exam : • Their size varies between 0. Infection 2.  Presentation : • Asymptomatic midline mass in the neck. common in ages between 15–30 years old.  Complications: 1. • The mass moves with protrusion of the tongue. • More common in women. Thyroid carcinoma (1-2%) 32 . • Dysphagia (if large) • Pain.

to prevent recurrence. Investigation: Ultrasound CT scan  Treatment: surgical resection. removal of Whole thyroglossal tract = Body of hyoid bone + Suprahyoid tract through tonge base (Sistrunk procedure). 33 .

Thyroglossal cyst Thyroglossal sinus 34 .

IV. Dermoid cyst 35 .

Dermoid cyst • It is a cystic teratoma that contains developmentally mature. and at the inner and outer end of the upper eyebrow. hair. solid tissues (skin. • Usually single. • It may be noticed at birth. sweat glands…). but it usually becomes obvious a few years later when it begins to distend. and benign. 36 . • Are common in the neck and face in the midline. • Rarely becomes infected. • Rarely large enough to cause any serious mechanical disability.

• Consistency: Solid or hard. • Shape and size: usually ovoid or spherical and 1-2 cm in diameter. • Nontender. • Relations: deep to the skin (in the subcutaneous tissue).• Surface: smooth. mobile. • Does not move with protruding the tongue  Treatment: surgical excision. 37 .

Cystic hygroma 38 .V.

• The only complaint is the lump.Cystic hygroma • • It is a congenital collection of lymphatic sacs that are derived from clusters of lymph channels that failed to connect and become normal lymphatic pathways.Breathing and swallowing difficulty . and the concern about the disfigurement by the parents.Infection Bleeding in the cyst 39 - . They contain clear. colorless lymph. • Commonly found at the base of the posterior triangle • Present at birth or within first few years of life. • May present with a complication: .

vary in size.  Treatment: surgical excision & removing all the abnormal 40 tissue. • They are close to the skin and contain clear fluid. . • They usually develop in the subcutaneous tissues. • Not tender. their distinctive physical sign is a brilliant translucence.• Could be lobulated or flattened in shape.

Sternomastoid tumor 41 .VI.

or if craniofacial asymmetry develops. • Attempts to turn the head straight may cause pain or distress. leading to torticollis. 42 . • Later on the lump disappear and the abnormal segment becomes fibrotic and contracted. • Surgery is reserved for patients in whom torticollis is present for more than one year. • Most often located in the inferior to the middle third of the sternocleidomastoid muscle. • Due to trauma at birth  infraction and edema. Some patients have small areas of residual fibrosis. Treatment: • Physiotherapy is recommended to achieve full range of motion.Sternomastoid tumor • Ischemic contracture of a segment of sternomastoid muscle.

and can be moved from side to side but not up and down.50 year old female presents with a pulsatile. compressible mass that refills rapidly on the release of pressure. Diagnosis? Carotid body tumor 43 .

VII . Carotid body tumor 44 .

• Moves from side to side but not vertically. • Non tender solid. • Usually benign. • The common presentation is a painless slowly growing lump. • Found in the upper part of the anterior triangle. • Size: 2-3cm to 10 cm in diameter. 45 . • Appear 40-60 years of age. but can occasionally be malignant (3%). hard mass.Carotid body tumors • Rare tumor of the chemoreceptor tissue in the carotid body.

Pulsatile. and the external carotid artery may pass over its superficial surface. 46 . the common carotid artery can be felt below the mass.

Postoperative hemorrhage or late stroke 2. o. 2.  Possible complication of the surgery: 1. Investigations: 1. Surgical resection for small tumors in young patients. Carotid angiogram to demonstrate the carotid bifurcation. Superior laryngeal nerve injury. MRI & CT Biopsy and FNA are contraindicated.  Treatment: o. Irradiation or close observation in elderly (surgery is best avoided in elderly due to it’s serious complication). 47 .

VIII . Pharyngeal pouch 48 .

regurgitation with bouts of coughing and choking. just above the cricopharyngeal muscle. • Mostly there’s no palpable swelling. • Associated with halitosis. • In middle and old age. below the level of thyroid cartilage. and may cause dysphagia. recurrent sore throat.Pharyngeal pouch • It is a diverticulum of the mucosa of the pharynx. but when appears it is behind 49 the sternomastoid muscle. . • Pressure on it causes gurgling sounds and regurgitation. • The swelling my change in size and often disappears. • Most patients have symptoms but no abnormal physical signs.

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