Surgery Endocrine

Neck masses

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12 أقسام

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Background

  • Neck masses can either be inflammatory/infectious, congenital or neoplastic
  • Lymphadenopathy is the most common neck mass
  • Neck masses in adults are cancer until proven otherwise (fine needle aspiration must be performed)
Neck masses
Inflammatory/infectious
  • Reactive lymphadenopathy
  • Cat scratch fever
  • Sarcoidosis
  • Kawasaki
  • HIV
Congenital Midline
  • Thyroglossal duct cyst
  • Thyroid tumor
  • Ranula
Lateral
  • Branchial cleft cyst
  • Cystic hygroma
Neoplastic Malignant
  • Lymphoma
  • Sarcoma
  • Salivary gland neoplasm
  • Neuroblastoma
Benign
  • Salivary gland neoplasm
  • Lipoma
  • Fibroma
  • Vascular

 

 

Version 2

Definition: Neck masses are abnormal swellings in the neck that can be inflammatory/infectious, congenital, or neoplastic in origin.

Epidemiology:

 

  • Most common neck mass overall: Lymphadenopathy (reactive)
  • Most common congenital neck mass: Thyroglossal duct cyst
  • Age-specific patterns:
    • Children: 90% benign (mostly inflammatory/congenital)
    • Adults >40 years: 80% malignant until proven otherwise ★
    • Rule of 80s: In adults, 80% of non-thyroid neck masses are neoplastic, 80% of neoplastic masses are malignant, 80% of malignancies are metastatic, and 80% of metastases are from primary sites above the clavicle

 

⚠️ High-Yield Clinical Pearl: Any neck mass in an adult (especially >40 years) requires fine needle aspiration (FNA) to rule out malignancy ★

Classification of Neck Masses
Inflammatory/Infectious
  • Most common: Reactive lymphadenopathy ★
  • Cat scratch disease (Bartonella henselae)
  • Infectious mononucleosis (EBV)
  • Mycobacterial infections (TB, atypical mycobacteria)
  • Sarcoidosis
  • Kawasaki disease
  • HIV lymphadenopathy
Congenital Midline
  • Thyroglossal duct cyst (most common) ★
  • Dermoid cyst
  • Thyroid masses
  • Ranula
Lateral
  • Branchial cleft cyst (most common lateral) ★
  • Cystic hygroma (lymphangioma)
  • Torticollis (fibromatosis colli)
Neoplastic Malignant
  • Adults: Metastatic squamous cell carcinoma (most common) ★
  • Children: Lymphoma (most common malignancy) ★
  • Thyroid carcinoma
  • Salivary gland malignancies
  • Neuroblastoma
  • Rhabdomyosarcoma
Benign
  • Pleomorphic adenoma (most common salivary tumor)
  • Lipoma
  • Fibroma
  • Hemangioma
  • Paraganglioma
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DIAGNOSTIC APPROACH -- Was not included in version 1

High-Yield Diagnostic Algorithm
Best Initial Test
  • Ultrasound with Doppler ★
    • Differentiates solid vs cystic
    • Evaluates vascularity
    • Guides FNA
Most Accurate Test
  • Tissue diagnosis (FNA or excisional biopsy) ★
  • CT with contrast for deep masses
  • MRI for soft tissue detail
Additional Studies
  • CBC with differential
  • ESR/CRP
  • Thyroid function tests
  • EBV titers (if mononucleosis suspected)
  • PPD/QuantiFERON Gold (if TB suspected)
  • HIV testing (if risk factors)
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Pediatric neck masses

Pediatric neck masses
Diagnosis Location Distinguishing features
Thyroglossal duct cyst Midline
  • Tract between foramen cecum and base of anterior neck
  • Cystic, moves with swallowing or tongue protrusion
Dermoid cyst Midline
  • Cystic mass with trapped epithelial debris
  • Occurs along embryologic fusion planes
  • No displacement with tongue protrusion
Branchial cleft cyst Lateral
  • Tract may extend to the tonsillar fossa (2nd branchial arch) or pyriform recess (3rd branchial arch)
  • Often associated with sinus tract/fistula
  • Anterior to the sternocleidomastoid muscle
Reactive adenopathy Lateral
  • Firm, often tender
  • Multiple nodules
Lymphadenitis Lateral
  • Tender, warm, erythematous
Cystic hygroma Posterior
  • Dilated lymphatic vessels

 

 

 

Version 2

Pediatric Neck Masses - High-Yield Features
Diagnosis Location Classic Features ★ Diagnostic Test
Thyroglossal duct cyst Midline
  • Moves with swallowing AND tongue protrusion ★
  • Most common at hyoid level (65%)
  • May become infected after URI
 Ultrasound (shows cystic mass)
Dermoid cyst Midline
  • Does NOT move with swallowing ★
  • Doughy consistency
  • Contains epithelial debris
 CT (shows fat density)
Branchial cleft cyst Lateral
  • Anterior to SCM muscle ★
  • 2nd cleft most common (95%)
  • May have sinus opening
 Ultrasound or CT
Cystic hygroma Posterior triangle
  • Transilluminates ★
  • Soft, compressible
  • Associated with Turner syndrome
 Ultrasound (shows multiloculated cysts)
Reactive lymphadenopathy Lateral (usually)
  • Multiple, mobile nodes
  • <2cm, soft
  • Tender if acute
 Clinical observation
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Thyroglossal duct cyst

Thyroglossal duct cyst
Embryology
  • Forms along path of thyroid descent
  • Foramen cecum (base of the tongue) to base of anterior neck
Clinical presentation
  • Midline cystic neck mass (second most common congenital anterior neck mass)
  • Moves superiority with swallowing or tongue protrusion
  • Often presents after upper respiratory tract infection (secondary infection)
  • Associated with ectopic thyroid tissue
  • Male predominance
Diagnosis
  • Ultrasonography (appears cyst)
Management
  • Confirm presence of normal thyroid tissue
  • Surgical resection of cyst, associated track and central portion of hyoid bone

 

 

 

version 2

Thyroglossal Duct Cyst
Embryology
  • Thyroid descends from foramen cecum to lower neck via thyroglossal duct
  • Duct normally involutes by 7-10 weeks gestation
  • Failure of involution → cyst formation ★
Epidemiology
  • Incidence: 7% of population
  • Most common congenital neck mass ★
  • Male:Female = 1.5:1
  • Bimodal: <5 years and 20-30 years
Clinical Features
  • Classic triad ★:
    1. Midline location
    2. Moves with swallowing
    3. Moves with tongue protrusion
  • 65% at hyoid level, 20% suprahyoid, 15% infrahyoid
  • Usually asymptomatic unless infected
  • 1-2% risk of malignancy (papillary thyroid carcinoma)
Diagnosis
  • Ultrasound: First-line imaging ★
    • Well-defined, anechoic cystic mass
    • Must confirm normal thyroid gland present
  • Thyroid scan: If thyroid not visualized on ultrasound
Management
  • Sistrunk procedure ★:
    • Excision of cyst
    • Excision of entire tract
    • Central portion of hyoid bone (prevents recurrence)
  • If infected: Antibiotics first, then surgery after resolution
  • Recurrence rate: 3-5% with proper technique

 

 

 

 

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Branchial cleft cyst

Branchial cleft cyst
Embryology
  • Remnants of the second Branchial cleft or cervical sinus
Clinical presentation
  • Painless, firm mass lateral to the midline
  • Anterior to sternocleidomastoid
Diagnosis
  • Ultrasonography
Management
  • Surgical resection of cyst
  • If infected, it should be incised and drained and then should be subsequently resected (after the resolution of the infection)

 

 

 

Version 2

Branchial Cleft Cyst
Embryology
  • Failure of obliteration of branchial apparatus
  • 2nd branchial cleft: 95% of cases ★
  • 1st cleft: 1%, 3rd/4th cleft: 4%
Clinical Features
  • Location: Lateral neck, anterior to SCM ★
  • Smooth, fluctuant, non-tender mass
  • May have fistula to skin or pharynx
  • Often presents after URI (secondary infection)
Type-Specific Features
  • 1st cleft: Near ear, may involve facial nerve
  • 2nd cleft: Classic location at mandible angle ★
  • 3rd/4th cleft: Lower neck, may present as thyroiditis
Diagnosis
  • Ultrasound: Well-defined cystic mass
  • CT/MRI: For surgical planning
  • Fistulogram: If sinus tract present
Management
  • Complete surgical excision including tract ★
  • If infected: I&D + antibiotics, then excision later
  • Recurrence: 3% with complete excision, 20% if tract remains

 

 

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Lymphadenopathy

Lymphadenopathy 
Reassuring  Worrisome
Palpation
  • Soft
  • Mobile
  • <2 cm (normal <1 cm)
  • Firm or hard
  • Immobile
  • >2 cm
Location
  • Localized
  • Generalized or supraclavicular (palpable supraclavicular lymph nodes are malignant until proven otherwise)
Systemic symptoms
  • Absent
  • Present
Further investigations
  • CBC
  • Viral titers
  • Inflammatory markers

 

 

Version 2

Lymphadenopathy Assessment
Reassuring Features Worrisome Features ★
Size <1 cm (normal)
<2 cm (reactive)		 >2 cm ★
Consistency Soft, mobile Hard, fixed, matted ★
Location Localized
Cervical chain		 Supraclavicular ★
Generalized
Duration <2 weeks >4 weeks ★
Associated Symptoms URI symptoms
Tender nodes		 B symptoms ★
Weight loss
Night sweats
Action Required
  • Supraclavicular nodes: Always pathologic, require immediate FNA ★
  • Persistent >4 weeks: FNA indicated
  • Hard, fixed nodes: Urgent evaluation for malignancy

 

 

 

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Cervical Lymphadenitis

Cervical lymphadenitis in children
Category Pathogen Key clinical findings
Unilateral
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Acute
  • Most common
  • Suppurative
  • Anaerobic bacteria
  • Acute
  • History of periodontal disease or dental caries
  • Francisella tularensis
  • Acute
  • History of contact with infected animal (eg, rabbit)
  • Mycobacterium avium
  • Chronic
  • Bartonella henselae
  • Chronic
  • Papule at site of cat scratch/bite
Content
  • Viral
  • Acute (eg, adenovirus) associated with self-limited URI
  • Subacute/chronic (eg, EBV, CMV) associated with mononucleosis symptoms

 

 

Version 2

Cervical Lymphadenitis in Children - High-Yield Pathogens
Category Pathogen Key Clinical Features ★
Unilateral S. aureus/S. pyogenes
(Most common) ★
  • Acute onset
  • Suppurative (may form abscess)
  • Overlying erythema
  • Fever present
Anaerobes
  • Associated with dental disease ★
  • Foul-smelling discharge
  • Submandibular location
Bartonella henselae
(Cat scratch disease)
  • Papule at inoculation site ★
  • Regional lymphadenopathy 2-4 weeks later
  • Low-grade fever
  • Cat exposure history
Mycobacterium avium
(Atypical mycobacteria)
  • Violaceous skin discoloration ★
  • Non-tender
  • No systemic symptoms
  • Age 1-5 years
Francisella tularensis
(Tularemia)
  • Rabbit/tick exposure ★
  • Ulceroglandular form most common
  • High fever
  • Painful adenopathy
Bilateral Viral
(Most common bilateral) ★
  • EBV: Posterior cervical, splenomegaly ★
  • CMV: Similar to EBV, heterophile negative
  • Adenovirus: Pharyngitis, conjunctivitis
  • HIV: Persistent generalized

 

 

 

 

 

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Squamous cell carcinoma of the head and neck

Squamous cell carcinoma of the head and neck summary
Pathogenesis
  • Significant history of alcohol and tobacco smoking
Clinical presentation
  • Persistent (>2 weeks), palpable (>1.5 cm), firm neck mass
Diagnosis
  • CT with contrast
  • Fine needle aspiration is preferred over open biopsy to avoid tumor seeding
Treatment
  • <2 cm: resection
  • >2 cm: resection and neck dissection

 

 

 

 

Version 2

Squamous Cell Carcinoma - High-Yield Facts
Risk Factors
  • Major risks ★:
    • Tobacco (6x risk)
    • Alcohol (synergistic with tobacco - 15x risk)
    • HPV (especially type 16) - oropharyngeal
  • Betel nut chewing
  • Prior radiation
Clinical Presentation
  • Classic patient: Male >50 years with smoking/drinking history ★
  • Red flags ★:
    • Firm neck mass >1.5 cm
    • Persistent >3 weeks
    • Associated hoarseness
    • Dysphagia/odynophagia
    • Otalgia (referred pain)
Most Common Sites
  1. Larynx (most common overall) ★
  2. Oropharynx (increasing due to HPV)
  3. Oral cavity
  4. Hypopharynx (worst prognosis)
Diagnosis
  • Best initial test: CT with contrast ★
  • Tissue diagnosis:
    • FNA preferred (avoids tumor seeding)
    • Core needle if FNA non-diagnostic
    • Avoid open biopsy ★
  • Panendoscopy: To find primary if unknown
Treatment
  • Early stage (T1-T2): Surgery OR radiation ★
  • Advanced stage (T3-T4): Combined modality ★
    • Surgery + adjuvant radiation
    • Concurrent chemoradiation
  • Neck dissection: If nodes >3 cm or multiple
Prognosis
  • HPV-positive: Better prognosis (70-90% 5-year survival) ★
  • HPV-negative: Worse prognosis (30-50% 5-year survival)
  • Early stage: 80-90% cure rate
  • Advanced stage: 40-50% cure rate

 

 

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HIGH-YIELD EXAM FACTS BOX

★ MUST-KNOW FACTS FOR EXAMS ★

  1. Adult with neck mass = cancer until proven otherwise (especially if >40 years)
  2. Thyroglossal duct cyst: Moves with swallowing AND tongue protrusion
  3. Branchial cleft cyst: Lateral, anterior to SCM
  4. Supraclavicular lymphadenopathy: Always pathologic
    • Right = lung, esophagus, mediastinum
    • Left (Virchow's node) = GI malignancy below diaphragm
  5. Sistrunk procedure: Must remove central hyoid bone
  6. Most common neck infections:
    • Acute bacterial: S. aureus/S. pyogenes
    • Chronic: Mycobacteria or cat scratch disease
  7. HPV-associated SCC: Better prognosis than smoking-related
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CLINICAL PEARLS

⚠️ HIGH-YIELD CLINICAL PEARLS

  • Cystic hygroma: Only neck mass that transilluminates
  • Dermoid cyst: Midline but does NOT move with swallowing (unlike thyroglossal)
  • Cat scratch disease: Look for papule at inoculation site
  • Atypical mycobacteria: Violaceous skin, no systemic symptoms
  • Rule of 7s: Lymph node concerning if >1 cm for >1 month in patient >40 years
  • Never do open biopsy of neck mass before imaging - risk of tumor seeding
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MEMORY AIDS

MEMORY AIDS

THYROGLOSSAL duct cyst moves with:

  • Tongue protrusion
  • Swallowing

Branchial Cleft Cyst Location - "BEAST":

  • Branchial
  • Exterior (lateral)
  • Anterior to
  • SCM
  • Triangle

Worrisome Lymph Nodes - "HELPS":

  • Hard
  • Enlarged (>2cm)
  • Lasting (>4 weeks)
  • Persistent
  • Supraclavicular
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