Neck mass

Background

Anatomy of the posterior pharynx.

Infrahyoid deep neck spaces

Neck anatomy at the level of the tongue.

Midline neck anatomy on lateral view.

• Common complaint seen in primary care medicine
• Important to recognize acutely life threatening etiologies, treatable disease, and potential for malignancy

Clinical Features

• Anatomy helpful in determining etiology
  • Anterior and posterior cervical triangles divided by SCM
• Associated symptoms based on etiology:
  • Pain
  • Skin changes
  • Stridor
  • Hoarseness
  • Fever
  • URI symptoms
  • Weight loss/night sweats
• Important to distinguish chronicity

• Assess for chronicity, associated symptoms, exposures (cats, undercook meat)
• Physical Examination
  • Benign reactive lymph nodes
    • Mobile, firm, and mildly tender
    • Clinical diagnosis
  • Lymphadenitis/suppurative disease
    • Painful, erythema, possibly fluctuant
    • Clinical diagnosis
    • CT imaging if concerns for deep space infection: trismus, torticollis, stridor, drooling
  • Extrapulmonary form of mycobacterium tuberculosis (cervical adenopathy)
    • Multiple bilateral lymph nodes
    • Fixed, firm, non-tender, located typically in posterior triangle
  • Cystic masses
    • Soft, mobile, ballotable
    • Thyroglossal duct cyst: midline, adjacent to hyoid, rises with swallowing
    • Branchial cleft cyst: lateral, mandibular angle anterior to SCM
    • Dermoid cyst: submental triangle
  • Malignant lesions
    • Hard, non-tender, and possible immobile
• Sialoadenitis
  • Tenderness to affected salivary gland and pus at the duct orifice
    • Parotid gland- stensen duct
    • Submandibular gland- wharton duct

Differential Diagnosis

Neck mass

Acute

• Reactive lymphadenopathy- most common
  • Viral URI
  • EBV
  • CMV
  • Strep/staph
  • HIV
  • Toxoplasmosis
  • Bartonella henselae- kitten or flea exposure
  • Tuberculous lymphadenitis (scrofula)
• Descending infections from oral cavity
  • Ludwig's angina
• Sialoadenitis (can also be chronic)
• Trauma-related
  • Hematoma
  • Pseudoaneurysm or AV fistula

Subacute (weeks to months)

• Cancer
  • HPV-related squamous cell carcinoma
  • Upper aerodigestive tract squamous cell carcinoma
  • Metastatic disease
  • Lymphoma
  • Parotid tumors
• Systemic diseases
  • Amyloidosis
  • Sarcoidosis
  • Sjögren syndrome

Chronic

• Thyroid nodules or cancer
• Goiters
  • Graves' disease
  • Hashimoto thyroiditis
  • Iodine deficiency
  • Lithium use
  • Toxic multinodular
• Congenital cysts
  • Branchial cleft cyst
  • Thyroglossal duct cyst- 2nd most common benign neck mass
  • Dermoid cyst
• Carotid body tumor
• Glomus jugulare or vagale tumor
• Laryngocele
• Lipoma/liposarcoma
• Parathyroid cysts or cancer

Evaluation

• CT or ultrasound only if diagnosis is unclear

Management

• Reactive lymphadenopathy: see specific diagnosis
  • Typically self resolving, supportive only except if related to bacterial disease
• Lymphadenitis
  • Trial antibiotics with either first-generation cephalosporins, amoxicillin/clavulanate (Augmentin), or clindamycin
• Suppurative lymphadenitis/abscess
  • Head and neck consultation may be necessary for drainage
• Sialoadenitis
  • Sialogogues, gentle massage, express gland through duct

Disposition

• Most commonly outpatient treatment either with trial antibiotics or supportive care only if inflammatory/infectious related
• Inpatient admission reserved for severe infections, surgical drainage, or concerns for airway compromise
• Follow up important to ensure appropriate resolution and further need for advanced imaging or biopsy

See Also

• Sore throat

References

• Haynes J, Arnold KR, Aguirre-Oskins C, and Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91(10):698-706./
• Kentab OY, Qureshi N. Chapter 118. Neck Masses in Children. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381590. Accessed August 11, 2016./