Neck mass symptoms, types, treatment, Malignant and Non-malignant neck lumps

The neck connects the head to the torso and contains vital structures from several systems. A neck mass refers to any abnormal lump or swelling in the neck. These can range from benign (non-cancerous) to malignant (cancerous) and may be caused by a variety of conditions.

Classification of Neck Mass

Neck masses can originate from: Skin, Endocrine organs, Upper aerodigestive Tract, Vessels, or Lymph Nodes. They are classified into: Congenital and Acquired.

• Inflammatory.
• Benign Neoplasm.
• Malignant Neoplasm.

Evaluation

Evaluation, which leads to the proper treatment and the best outcome, follows the following 4 steps:

1. Appropriate initial assessment.
2. Role and technique of FNAB.
3. Appropriate use and interpretation of imaging
4. Management: The importance of specialized multidisciplinary care if malignancy is suspected.

Appropriate Initial Assessment

A careful history and examination can often help make the correct diagnosis of a lump in the neck. The clinical signs of size, site, shape, consistency, fixation to skin or deep structures, pulsation, compressibility, transillumination, or the presence of a bruit remain as important as ever.

• Age.
• Location.
• Risk Factors.
• Symptoms.
• Head & Neck Exam.
• General physical exam.

Age

• Children (Pediatric): Inflammatory, congenital, and Malignant-
• Young Adult: Congenital, Inflammatory, and Malignant.
• Adult (>40): Malignant, Congenital, and Inflammatory.

Location

Common neck mass locations include the following:

• Angle of mandible: parotid swelling.
• Lateral neck: Enlarged lymph nodes (LNs) – Central compartment: Thyroid swelling.

Role of 80% of neck masses

Cases of neck masses: 80% are neoplastic, of which 80% are malignant, of which 80% are metastatic.

Risk Factors

• Tobacco.
• Alcohol.
• HPV (Human Papiloma Virus) and HN (Head and Neck cancer).
• Male predominance in Cancer.
• Younger patients.
• Fewer traditional risk factors.
• Sexual behavior as a risk factor for multiple sexual partners (>6), higher rates of oro-genital contact with multiple partners.
• Sun Exposure, Ex, farmer.

Symptoms of Head and Neck Primary

• Otalgia, unilateral.
• Hemoptysis.
• Nasal obstruction (snoring).
• Unilateral hearing loss.
• Dysphagia.
• Epistaxis.
• Hoarseness.
• Sore throat.

Symptoms of Lymphoma

• Fever.
• Night Sweats.
• Weight Loss.

Physical Exam: What do we need to document?

• Location of the mass in the neck.
• Presence/absence of a primary in the head and neck.
• Presence/absence of generalized lymphadenopathy.

Non-neck mass

• Transverse processes of cervical vertebrae.
• Carotid bulb.
• Inferior belly of the omohyoid.

Role and Technique of FNAR

• Needle size 25 gauge.
• 12-15 Passes should be performed.
• Immediate assessment of adequacy by the Pathologist is the rule.

Fine Needle Aspiration Biopsy

Diagnosis of Lymphadenopathy

• Sensitivity 85-97%.
• Specificity 98-100%.
• Nondiagnostic 8-16%.
• Open Biopsy 22-30%.

Role of Open Lymph Node Biopsy

• Excisional/Incisional Biopsy may be necessary:
• Sub classification of lymphoma.
• Facilitate the diagnosis of poorly differentiated carcinoma.
• Persistently nondiagnostic FNAB.

IV Management: The importance of specialized multidisciplinary care cannot be emphasized more, particularly if malignancy is suspected:

• Benign
• Malignant

Non-malignant neck lumps

• Bening.
• Inflammatory.

1. Cystic hygroma (Lymphangiomas)

• It is a congenital lesion usually present within the first year of life. (Posterior Triangle).
• Usually remain unchanged into adulthood.
• Soft, cystic, multilocular, partially compressible, and brilliantly transilluminant, and may present with pressure effects.
• CT or MRI may help define the extent of the neoplasm.
• Treatment of Lymphangiomas includes injection with picibanil or excision for easily accessible lesions or those affecting vital functions.
• If it affects vital function and structure.
• Injection is very hazardous.

2. Branchial cleft cysts

• Remnant of branchial cleft (2nd).
• Most commonly occur in the second or third decades.
• Pain +/- (severe throbbing pain) (not infected = mild aching pain).
• Usually presents as a smooth, fluctuant non non-tender (tender), non-transilluminant mass mobile forwards and downwards, underlying the anterior border of the sternomastoid muscle.
• Branchial fistula or sinus (infection).
• Primary treatment is with control of infection by antibiotics. followed by surgical excision.

3. Thyroglossal duct cyst

• This is a common congenital midline neck mass.
• Sometimes at the lateral edge.
• Pain and tenderness
  
• Can be moved transversally, but
• Elevates on the protrusion of the tongue.
• Treatment is with initial control of infection with antibiotics, followed by surgical excision including the mid-portion of the body of the hyoid bone (Sistrunk’s procedure).
• Occasionally, these lesions become infected and resolve, or persist following drainage as a thyroglossal fistula.

4. Lipoma

• Lipomas are the most common benign soft tissue neoplasm in the neck.
• They are poorly defined, soft masses usually after the fourth decade.
• They are usually asymptomatic, soft.
• FNAC or MRI Scan can confirm the diagnosis. MRI is the best.
• Surgery is indicated when the lump is increasing in size. cosmesis or when there is doubt about the accuracy of the diagnosis.

5. Sebaceous cysts

• These are common masses occurring often in older people, but can occur at any age.
• They are slow-growing, but sometimes fluctuant and painful when infected.
• Diagnosis is made clinically; the skin overlying the mass is adherent, and a punctum is often identified.
• Excisional biopsy confirms the diagnosis.

6. Cervical lymphadenopathy

Acute lymphadenitis

• tender swelling.
• Antibiotic trial, less acute inflammatory nodes generally regress in size over 2-6 weeks.
• If the lesion does not respond, the biopsy is warranted.

TB cervical lymphadenitis

• Upper and middle deep cervical LN.
• Onset: gradually.
• Pain: +/-
• Systemic symptoms are unusual in the young.
• Abscess (painful, increase size, and skin discoloration).
• Mass: indistinct, firm, matted, fluctuate!
• Temperature! (Cold abscess) (hot if see infection).
• Treatment with anti-TB (6- 9 months) Rifampicin Ethambutol INH Pyrazinamid.

7. Carotid body tumor

• Rare tumor of chemo receptors) (40-60 years).
• Slow-growing painless some time pulsating lump may be bilateral.
• Side-to-side movement (not along the carotid).
• Symptoms of transient cerebral ischemia!
• also known as Potato tumors (hard, non-tender).
• Palpation may induce a vasovagal attack.
• Biopsy is contraindicated: MRI (as its avascular mass).
• Angiography is the investigation of choice.
• Surgical removal is based on patient factors and presenting symptoms.

8. Pharyngeal pouch

• Diverticulum of the pharynx through the gap between the horizontal fibers of the cricopharyngeus muscle below and the lowermost oblique fibers of the inferior constrictor muscle above.
• History of froth and acid taste.
• Halitos is the regurgitation of food. There is no bile. or to it. (bad odor).
• Pressure on the swelling causes gurgling sounds and regurgitation.
• Treatment: cricopharyngeal myotomy.

9. Ludwig’s angina

• Rare but serious connective tissue infection of the floor of the mouth.
• Mostly due to dental infections.
• Signs of inflammation are present.
• Treatment: drainage of pus + antibiotic to cover aerobes with anaerobes.

10. Thyroid masses

• Thyroid neoplasms are a common cause of anterior compartment neck masses in age groups, with a female predominance, and are mostly benign.
• Fine needle aspiration of thyroid masses has become the standard of care, and ultrasound may show whether the mass is cystic.
• Unsatisfactory aspirates should be repeated, and negative aspirates should be followed up with a repeat FNAC and examination in 3 months.

Characteristics of malignant neck lumps

1. Lymphomas

• Painless lump: non-tender, smooth, and discrete.
• Slow growing.
• Patient presented with malaise, weight loss pallor.
• Fever, rigor and Hepatosplenomegaly.
• Mediastinal mass (SVC syndrome).
• Abdomin pressure on IVC may cause bi lateral leg oedma.
• Other lymph nodes in the axilla, groin, and abdomen should be examined.
• Treatment: according to stage (radiosensitive).

2. Metastatic Lymph Nodes (commonest)

• Upper cervical lymph nodes (upper aero-digestive tract).
• Accessory chain of nodes in the posterior triangle (Nasopharyngeal malignancies).
• (Occult primary) The most common sites are the tonsil, base of tongue, nasopharynx, and the Pyriform sinus.
• Virchow’s LN (Troisier ‘s sign), abdominal and thoracic malignancies.
• Painless, non-tender, and hard masses.
• Work up: Search for the primary and deal with it.