Neck masses

Landmarks
1. Hyoid bone
2. Thyroid cartilage
3. Cricoid cartilage
4. Trachea
5. Sternocleidomastoid
muscles
 Anatomy of the neck
• The sternocleidomastoid muscle divides each side of the neck
into 2 major triangles:
1. Anterior triangle
– Submandibular triangle
– Submental triangle
– Carotid triangle
– Muscular triangle
2. Posterior triangle
– Occiptal triangle
– Supraclavicular triangle
 Occipital triangle

Subclavian triangle
 Anterior triangle
Borders:
1. Laterally: anterior border of the SCM
2. Medially: midline
3. Superiorly: lower border of the mandible
 Posterior triangle
Borders:
• Anteriorly: posterior border of the SCM
• Inferiorly: 1/3 of clavicle
• Posteriorly: anterior border of trapezius muscle
 Head & neck LNs
• Superficial & deep
• Cervical LNs:
1. Anterior cervical
– Anterior jugular chain
– Justavisceral chain (prelaryngeal, pretracheal &
paratracheal)
2. Lateral cervical
– Superficial external jugular group
– Deep internal jugular (upper, middle & lower)
3. Posterior cervical
– Spinal accessory chain
– Transverse cervical chain
LNs
 Classification of neck
nodes accoding to levels

• Level I: submental & submandibular

• Level II: upper jugular
• Level III: middle jugular
• Level IV: lower jugular
• Level V: spinal accessory, transverse cervical
• Level VI: prelaryngeal, pretracheal & paratracheal
• Level VII: nodes of upper mediastinum
 Neck masses
• Defintion: any abnormal enlargement, swelling, or
growth between clavicles & mandible.
SEBACEOUS CYST
Most common causes
1. Lymphadenopathy
2. Thyroid disorder
3. Graves Disease
4. Hashimoto's Thyroiditis
5. Otitis media
6. Sebaceous cyst Thyroid swelling
7. Larynx Cancer
8. Lymphoma
9. Mumps
10. Rubella
11. Thyroid cancer
12. Tuberculosis
Classification of neck masses
1. True & pseudo masses
2. Acquired & congenital

True masses
• Midline masses (congenital is most common)
• Lateral masses

Pseudo masses
• Lateral process of axis
• Enlarged styloid process
• Cervical rib
• Tortuous atherosclerosis carotid
Congenital
– Midline
• Thyroglossal cyst
• Dermoid cyst
– Lateral
• Branchial cyst
Acquired
– Inflammatory
– Neoplastic
– Traumatic (hematoma)
 Congenital neck masses
1. Thyroglossal Cyst (most common)
2. Branchial Cyst.
3. Dermoid.
4. Hamartoma.
5. Teratoma.
6. Lipoma.
7. Laryngocele.
8. Diverticulum.
9. Cystic Hygroma.
 THYROGLOSSAL CYST
• Fibrous cyst that forms from a
persistent thyroglossal duct
• Most common congenital neck mass
• Childhood
• Midline mass
• Elevated with tongue protrusion
• Painless (if infected 🡪 painfull)
• Smooth and cystic

Presentations:
• Dysphagia.
• Breathing difficulty.
• Dyspepsia especially if large mass. Rx:
• Total resection with central part of
hyoid bone to avoid recurrence.
 Branchial Cyst
• Remnants of embryonic
development
• Result from failure of obliteration
of the branchial cleft
• Cystic mass
• Develops under the skin between
SCM & pharynx.

Presentation:
• Asymptomatic (mostly)
• Painful if become infected.
Rx:
• Surgical excision
• Complete surgical excision may
be difficult, so they can recur.
 Dermoid cyst
• Cystic teratoma
• Contains mature skin complete with hair follicles and sweat gland.
sometimes clumps of hair, and often pockets of sebum, blood, fat.
• Almost always benign and rarely malignant.
• Midline mass
• Not move with protruding the tongue
• Solid or hard in consistency.
• Usually limitted to the skin
Rx:
• Complete surgical removal.
Ranula
• Cystic swelling floor of
mouth
• Mucous extravasation from
sublingual salivary gland
Plunging Ranula :-

extend through mylohyoid muscles into neck

 Inflammatory lumps
Acute inflammation: Chronic inflammation:
• URTI • TB
• Ears • Sarcoidosis
• Tonsils • Cat scratch disease
• Syphilis
• Brucillosis
TUBERCULOUS ADENITIS
 Neoplastic Neck Masses
• Benign or malignant
Primary (above clavicle):
• Lymphomas (most common)
• Squamous cell carcinoma of branchial cyst.
• Melanoma
• Rabdomyosarcoma
• Present late and the only presentation could be
lymphadenopathy.
Secondary: below clavicle (virchow’s node)
• Breast (98%), lung, liver, stomach, prostate.
• Above clavicle 🡪 advanced stage of tumor.
 Primary-Benign
• Any structure may be involved
• Skin, SC Tissue, fat, nerve, muscle, vessel.
• Lipoma, fibroma, haemangioma, neuroma
• Salivary gland: Pleomorphic adenoma, Wharthins
tumour
• Thyroid: Multinodulargoitre, cyst, adenoma
 Primary-Malignant
• Salivary gland
• Thyroid gland
• Lymph nodes: Lymphoma
• Sarcoma…
Carotid body tumor
• Originate from small chemoreceptive and baroreceptive
organs
• Located at the adventitia of the common carotid artery
bifurcation. (paragangliomas)
 Approach
History
• PP: (Age, Sex)
– Child: congenital or inflammatory
– Middle: tumor or infl.
– Old: tumor
• HPI:
– Duration
– Painfull/painless
– Associated Sx (sore throat, URI symptoms)
• SR
– General (fever, weight loss, malaise…)
– Symptoms of hypo/hyperTHYRODISM
– Difficulty swallowing or speaking (esophageal ca)
– Respiratory Sx
– GI Sx
• Past medical history
– HIV or TB
– Ill-fitting dental appliances
– Chronic oral candidiasis
• Medication & radiation .
• Social History : smoking , alcohol , contact with T.B.
• Travel History
 Physical examination
1. Inspection :
a. site b. shape c. color d. relation to swallowing.
e. relation to tongue protrusion .
2. Palpation :
a. temperature . b. tenderness . c. size .
d. surface . e. edge . f. consistence .
g. fluctuation . h. pulsatility . i. relation to skin .

j. mobility . k. relation to underlying structures .

3. Percussion :
for retrosternal extension of the thyroid .

4. Auscultation :
 Complete Head & Neck Examination

1. Look for any mass or ulcer

2. L.N.
3. Ear , nose & throat examination
4. Sinuses
5. Mouth examination
6. Thyroid
7. Pharynx, larynx
8. Liver, spleen
9. LNs of body (axilla, inguinal)

Systemic examination
• RS
• GI
 Investigations
Rules of investigations:
1. Effective in Dx & or assessment of the disease.
2. Harmless.
3. Cost-effective.
4. Guided by medical suspecion.

Types of investigation:
5. Radiological
6. Labs for TB, sarcoidosis,
Hematological(lymphoma,leukemia).
7. Endoscopy & biopsy
8. FNA (diagnostic)
 Radiological
• X-ray (not helpful).
• Barium swallow in hypopharyngeal
diverticulum.
• US: differentiate btw solid & cystic masses
• CT: assessment of the mass itself.
• MRI: nature of the mass
 Endoscopy & Biopsy
• Fibro-optic or rigid endoscopy
• Nose-larynx-pharynx-esophagus-mouth.
• Take biopsy:
– If u cannot find the primary lesion in the neck, take Bx
from suspected places.
• Base of the tongue.
• Tonsils.
• Nasopharynx.
• Pyriform fossa.
• Supraglottic.
 FNA
• FNAB is the STANDARD of diagnosis for neck masses If u
suspect malignancy.
• 90% of cases it gives true Dx.
• Could have false –ve or false +ve.
• Differentiate btw inflammatory & neoplastic masses.
 RADIONUCLEOTIDE SCANNING

• Differentiate a mass from

within or outside a glandular
structure.
• Also indicate the functionality
of the mass.
• Important for salivary and
suspected thyroid gland
masses.