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10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018
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Image from Gandhi RA, Bhowate R, Degweker S, Bhake A. Case Rep Dent. 2011;2011:978263. [Open access.] PMID: 22567451, PMCID: PMC3335588.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
The image is from a 14-year-old female who presented with a 1-month history of swelling in the left submandibular region above the hyoid bone and a sore throat. Fine-needle aspiration (FNA) cytology revealed a thyroglossal cyst. She underwent successful complete surgical excision of the cyst.
The differential diagnosis of a neck mass varies based on the age of the patient, the location of the lesion, and the history and physical examination findings. In the pediatric population, neck masses are most commonly due to reactive or infectious lymphadenopathy. Congenital neck lesions such as branchial cleft or dermoid cysts are also an important consideration in children. In adults, a persistent neck mass should be considered a malignancy until proven otherwise.
Evaluation and management of a neck mass depends on the clinical context; the workup and treatment may include observation, imaging, FNA, incisional or excisional biopsy, administration of antibiotics, neck dissection, or excision of the lesion.
Image courtesy of Wikimedia Commons | Drahreg01.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 44-year-old female presents with a slow-growing, nontender anterior neck mass (shown). She complains of heat intolerance and reports an unintentional 10-pound weight loss over the past month. Upon palpation of the central neck, you note diffuse enlargement of the thyroid.
What is the best next step in the evaluation of this patient?
Thyroid function tests, including levels of thyroid-stimulating hormone (TSH) and free thyroxine (T4)
Open thyroid biopsy
FNA biopsy
Computed tomography (CT) scanning of the neck with iodine-based contrast medium
Image courtesy of Wikimedia Commons | KGH.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: A. Thyroid function tests, including levels of TSH and free T4
This histopathologic image shows diffuse hyperplasia of the thyroid gland. The patient is presenting with clinical signs/symptoms of hyperthyroidism, including heat intolerance, weight loss, anxiety, restlessness, palpitations, tremor, sweating, menstrual irregularities, and insomnia.[1-3] Thyroid function tests may reveal low levels of TSH and high levels of free T4, possibly with elevated thyroid-stimulating immunoglobulin levels.[3]
If a patient has a classic history, as well as classic physical examination findings and laboratory results for hyperthyroidism, no further testing is necessary. Treatment depends on the cause and severity of the symptoms. Therapeutic options include antithyroid agents, radioiodine (RAI) therapy, and thyroidectomy.[1-3]
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 20-year-old male presents with fever and a tender left neck mass that has been increasing in size over the past week. He denies any difficulty breathing or eating. Previously, two similar episodes were treated with incision and drainage (I&D) and oral antibiotics. The patient denies smoking, drinking alcohol, or using any illicit drugs. The CT scan shows the patient's sternocleidomastoid muscle (s) and the mass (m).
What is the most likely diagnosis based on the history and CT scan findings?
Infected thyroglossal duct cyst
Metastatic oral squamous cell carcinoma (SCC)
Metastatic papillary thyroid cancer
Infected branchial cleft cyst
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: D. Infected branchial cleft cyst
Branchial cleft cysts, sinuses, and fistulas are congenital anomalies related to aberrant embryologic development.[4,5] A branchial cleft cyst is an epithelium-lined sac with no opening; a sinus has a single opening, and a fistula has two openings.
First branchial cleft cysts occur as a membranous duplication of the external auditory canal or along the angle of the mandible. The first branchial cleft cyst (m) in this image is adjacent to the right submandibular gland (g).[6] Second branchial cleft cysts are the most common type of congenital branchial lesions (95%); they are located deep to the sternocleidomastoid muscle and can form a sinus (incomplete) or fistula (complete) tract that travels between the external and internal carotid arteries.
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Third branchial cleft cysts are rare, but they can arise along the inferior sternocleidomastoid muscle (s).[6,7] Their tracts travel between the hypoglossal and glossopharyngeal nerves to pierce the thyrohyoid membrane and enter the piriform sinus (shown) (m = third branchial cleft cyst).
The diagnosis of branchial cleft cyst can usually be made on the basis of CT scan findings in conjunction with the appropriate clinical history.[6-8] Definitive treatment options include piriform sinus tract chemical/heat cautery and/or surgical excision[5-8]; antibiotic therapy is used to treat infections or abscesses related to branchial cleft cysts.[5]
Image courtesy of Wikimedia Commons | Ph0t0happy.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
An 18-year-old female presents with a progressively enlarging floor-of-mouth lesion, a submental neck mass, and dysphagia. She states the mass has been slowly growing for the past 2 years. Her roommate reports that the patient is snoring louder and louder. On physical examination, the patient has a nontender, soft mass at the base of the right tongue on the floor of mouth (shown). There are no overlying mucosal irregularities. The submental neck mass is also soft and fixed, without any overlying skin changes.
What is the most likely diagnosis on the basis of the history and physical examination findings?
Thyroglossal duct cyst
Teratoma
Plunging ranula (mucocele)
Foregut duplication cyst
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: C. Plunging ranula (mucocele)
A ranula is a mucous retention cyst that occurs in the floor of mouth as a result of sublingual duct obstruction.[9-11] Plunging ranulas extend through the mylohyoid muscle into the neck. Simple ranulas present as a unilateral, slow-growing, painless, bluish mass on the mouth floor[9,10]; congenital ranulas may cause acute airway obstruction in infants and young children.[10] Plunging ranulas may present as neck swelling (shown) with or without an oral cyst[9]; they are usually found in the submandibular space, and they must be differentiated from hematomas, lymphangiomas, branchial cleft cysts, and dermoid cysts.[10,11] If drained, ranulas contain clear, thin fluid.
The diagnosis can be made based on the physical examination. Imaging studies (CT scanning, magnetic resonance imaging [MRI]) may be necessary to differentiate plunging ranulas from other cystic neck masses, to determine the extent of the ranula, and to facilitate planning for surgical excision. Resection usually requires removal of the cyst and the affected sublingual gland. Alternative management options include observation for spontaneous resolution (may recur within 5 months), I&D, cryotherapy, and marsupialization.[9,11]
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 15-year-old male presents with an anterior neck mass that has grown progressively over the past 5 years. He denies any fever, weight loss, night sweats, difficulty breathing, or dysphagia. The mass has never been infected. On physical examination, there is a small, mobile midline neck mass that elevates with tongue protrusion. The patient undergoes a CT scan with contrast medium (shown). A normal-appearing thyroid gland is noted on the CT scan.
What is the next step in the management of this patient?
Biopsy the mass
Perform a Sistrunk procedure
Perform a neck dissection
Administer cephalexin for 7-10 days
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
The image shows a surgical specimen from a previously infected thyroglossal duct cyst and tract.
Answer: B. Perform a Sistrunk procedure
Thyroglossal duct cysts are the most common midline congenital neck masses.[12] They are caused by failed obliteration of the thyroglossal duct, an embryologic tract between the foramen cecum of the tongue and the thyroid gland.[12,13] They may present as a painless midline neck mass or as a tender, inflamed mass if infected; patients may have dysphagia or airway obstruction.[13,14] On physical examination, the cysts usually elevate with tongue protrusion because of their embryologic origin,[13,14] which can help to distinguish them from dermoid cysts, enlarged lymph nodes, lipomas, lymphatic malformations, and other neck masses.
The diagnosis can be made clinically in children or with the aid of ultrasonography. It is important to note the presence of a normal thyroid gland because, rarely, these cysts contain the only viable thyroid tissue. A CT scan or MRI is usually not necessary in children with a classic history and classic examination findings. Treatment is a Sistrunk procedure that involves resection of the cyst, tract, midportion of the hyoid bone, and a cuff of tissue from the base of the tongue musculature.[13] Antibiotics are used to treat infected cysts.
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 55-year-old female presents with a 6-month history of a progressively enlarging left neck mass. She was initially evaluated by her primary care physician and given a 10-day course of amoxicillin. The mass did not respond to medical therapy; therefore, a CT scan of the neck with contrast (shown) was ordered, and the patient was referred for further evaluation. On physical examination, a firm, nontender, mobile mass of the upper left neck is noted. The patient has bilateral, symmetrical facial nerve movement.
What is the most likely diagnosis of this patient's neck mass?
Metastatic thyroid cancer
Pleomorphic adenoma
Rhabdomyosarcoma
Glomus tumor
Image courtesy of Wikimedia Commons | KGH.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A histologic image of pleomorphic adenoma is shown.
Answer: B. Pleomorphic adenoma
The parotid gland is the most common site for salivary gland tumors.[15,16] Pleomorphic adenomas are benign, mixed tumors that may undergo malignant change.[15,16] Adults usually present with a painless, slow-growing neck mass.
Small tumors can be evaluated through ultrasonography,[17-19] which usually shows smooth, round, hypoechoic masses with distal acoustic enhancement.[17] FNA biopsy may facilitate surgical planning and patient counseling.[18,19] CT scan or MRI studies are used to assess large tumors to differentiate them from other neck masses, to predict potential malignancy, and to reveal the tumor extent/location.[17-19] Contrast CT scans usually reveal a well-circumscribed, enhancing mass; surface nodularity may be present.[17] Treatment for parotid masses is a superficial or total parotidectomy with facial nerve preservation; malignant lesions may require a neck dissection and/or postoperative radiotherapy.[18,19]
Image courtesy of Wikimedia Commons | James Heilman, MD.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
An 18-year-old male presents with slow-growing, bilateral neck masses (arrows). He says his symptoms began 3 weeks ago with a sore throat. Since then, there has been a slight improvement in his sore throat, but he has had intermittent fevers and progressive malaise. On physical examination, the patient has bilateral enlarged tonsils, but no exudates. The bilateral neck masses are soft and mobile. Patchy erythema of the anterior neck and chest (shown) is also present.
What is the most likely etiology for this patient's signs and symptoms?
Cat scratch fever
Tuberculosis
Mononucleosis
Actinomyces infection
Image courtesy of Flickr | Ed Uthman, MD.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: C. Mononucleosis
Cervical lymphadenitis, the inflammation or enlargement of a cervical lymph node, is one of the most common causes of neck masses in the pediatric population[20,21]; common causative organisms include beta-hemolytic streptococci, Staphylococcus aureus, Epstein-Barr virus (EBV) (mononucleosis), and cytomegalovirus.[20] Atypical mycobacterium, Bartonella henselae (cat scratch disease), and tularemia are granulomatous causes of lymphadenopathy or suppurative lymphadenitis. Findings from the patient's history and physical examination direct diagnostic testing for cervical lymphadenitis.
Lymphocytosis (shown in the peripheral smear image) is common in infectious mononucleosis; an EBV heterophile antibody test confirms the diagnosis.[22] Mononucleosis is usually treated with bed rest, hydration, and avoidance of splenic trauma; steroids should be used for severe tonsil swelling and for impending or established airway obstruction. In rare cases of splenic rupture caused by EBV mononucleosis, urgent surgical intervention (splenectomy) is required.[22]
Adapted image courtesy of Wikimedia Commons | JHeuser.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 30-year-old male presents with a left neck mass that has slowly enlarged over the past 2 months. The mass has grown progressively despite two courses of antibiotics and a steroid taper. Over the past 3 weeks, the patient has also had fever, generalized pruritus, and an unintentional 10-pound weight loss. On physical examination, there is a firm, nontender, mobile left neck mass that extends into the supraclavicular fossa. A CT scan demonstrates bilateral enlarged lymph nodes (shown).
What is the most likely diagnosis given this patient's age, signs, and symptoms?
Lymphoma
Metastatic SCC
Tuberculosis
Thyroid cancer
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: A. Lymphoma
Lymphoma refers to any cancer arising from lymphocytes, and it is generally classified as Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL).[23] It can occur at any age. Patients with HL commonly present with nontender lymphadenopathy, fever, weight loss, and night sweats (“B symptoms”).[24,25] HL risk factors include male sex, family history, previous EBV infection, and age between 15 and 40 years.[25] NHL symptoms/signs are similar to those of HL.[26,27] Risk factors for NHL include immunodeficiency, exposure to radiation or certain chemicals (eg, benzene, herbicides/insecticides), and autoimmune diseases.[27]
Excisional lymph node biopsy is preferable to core needle biopsy to establish the diagnosis of HL.[25,27] Reed-Sternberg cells (arrows) are a classic histologic finding of HL.[23,25] Cerebrospinal, pleural, and/or peritoneal fluid sampling and/or other laboratory studies may be needed to classify the type of lymphoma.[27] Treatment depends on the type and stage of lymphoma but usually involves radiotherapy, chemotherapy, or a combination chemotherapy regimen; immunotherapy, stem cell transplantation, and surgery are also treatment options.[24-27]
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 64-year-old male presents with a left neck mass that he noted incidentally while shaving the previous month. He does not think that it has grown significantly. He denies any difficulty breathing, dysphagia, fever, or night sweats, but he has had a 15-pound unintentional weight loss over the past 2 months. He has a 30 pack-year smoking history and drinks socially. On physical examination, there is an ulcerated lesion on the left floor of his mouth that extends to the lateral tongue. A left, firm and fixed, 3- × 3-cm, level-2 lymph node is present. A combined CT/positron emission tomography (PET-CT) imaging study is ordered (shown).
On the basis of the patient's clinical and radiologic findings, what is the most likely diagnosis?
Metastatic thyroid cancer
Lymphoma
Metastatic SCC
Metastatic adenocarcinoma
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: C. Metastatic SCC
The PET-CT scan on the previous slide showed increased fluorodeoxyglucose (FDG) uptake in the left floor of the mouth and nodal disease (above the hyoid bone, thus level II[28]). SCC—the most common cancer of the oral cavity[29]—may also produce necrotic lymph nodes (arrows)[30] (SCM = sternocleidomastoid muscle). Risk factors for SCC include smoking and alcohol use (major factors),[30,31] male sex, and human papillomavirus infection.[31] Focus the history on the duration of the mass and the patient's smoking and alcohol use, as well as on symptoms/signs such as difficulty breathing, dysphagia, fever, night sweats, and weight loss. It is important to identify neck nodes on physical examination, because cervical lymph node metastasis has a poor prognosis and can decrease survival rates by 50%.[32,33]
The diagnostic evaluation includes cytologic/histologic studies, imaging studies, and panendoscopy (endoscopy of the upper gastrointestinal tract) with biopsies.[33,34] In general, early stage disease is treated with surgery or radiotherapy; advanced disease requires multimodal therapy, such as surgery and radiation therapy or chemotherapy and radiation treatment.[33,34]
Image courtesy of Wikimedia Commons | The Armed Forces Institute of Pathology.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 40-year-old woman presents with an anterior neck mass that has been growing over the past 2 years. As it has grown, she has noticed progressive difficulty breathing when lying supine; she now sleeps on two pillows. She denies fevers, night sweats, and weight loss. On physical examination, she has a firm 3- × 2-cm mass in her left thyroid lobe. Histologic findings from an FNA biopsy, including a psammoma body (arrow), are shown.
What is the diagnosis?
Follicular thyroid cancer
Papillary thyroid cancer
Thyroglossal duct cyst
Lymphoma
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: B. Papillary thyroid cancer
Papillary cancer is the most common type of thyroid cancer (80%); it has an unknown etiology.[35] Risk factors include radiation exposure,[35-37] female sex,[35-37] and family history.[36,37] Patients commonly present with an anterior neck mass and may not have other symptoms/signs (eg, dysphagia, dyspnea, cough).[35,37]
The workup includes thyroid function tests, ultrasonography, and FNA biopsy. Papillary thyroid cancer is well differentiated and has characteristic histologic findings, including psammoma bodies and nuclear pseudoinclusions.[37] Treatment options for papillary thyroid cancer include surgical resection (shown) and/or radioactive iodine ablation or external radiotherapy.[35-39] In advanced cases, a combination of these therapies may be used in conjunction with hormone therapy, chemotherapy, and/or targeted therapy. In general, the prognosis of papillary thyroid cancer is excellent.[35-39]
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
A 52-year-old female presents with a left neck mass that has been slowly growing over the past 10 years and is now giving her trouble with swallowing. The patient denies any fever, night sweats, or weight loss. She also denies smoking, alcohol consumption, and illicit drug use. On physical examination, she has left eyelid ptosis, and her left pupil is constricted. A large, soft, level-2, left neck mass is present. A CT scan with contrast is ordered (shown).
What is the most likely diagnosis in this patient?
Pleomorphic adenoma of the left parotid
Adenoid cystic carcinoma of the left parotid
SCC of the left tonsil
Left carotid body tumor (glomus tumor)
Image courtesy of Medscape.
10 Patients With Neck Masses: Identifying Malignant Versus Benign
Eelam Aalia Adil, MD, MBA; David Goldenberg, MD, FACS | February 6, 2018 | Contributor Information
Answer: D. Left carotid body tumor (glomus tumor)
The CT scan on the previous slide shows a large, enhancing, left-side tumor that extends into the parapharyngeal space. Carotid body tumors (also known as glomus tumors, chemodectomas, or paragangliomas) are rare, asymptomatic, slow-growing tumors.[40] Patients may present with cranial nerve palsy and tongue weakness, absent gag reflex, shoulder weakness, or Horner syndrome.[40,41] The mass is usually soft and vertically fixed (Fontaine sign) because of its attachment to the carotid bifurcation; a bruit may be felt or heard.[40,41] Most glomus tumors are nonfunctional neuroendocrine tumors, but preoperative urinary vanillylmandelic acid, homovanillic acid, and metanephrine levels must be checked to prevent intraoperative catecholamine crisis.
Imaging studies include ultrasonography, CT scanning, magnetic resonance angiography, and digital subtraction angiography (shown).[40,41] Treatment of carotid body tumors is controversial but generally consists of surgery or radiotherapy. Other, debated therapeutic options include embolization[40,41] and stereotactic radiosurgery.[40]
Although many skin cancers are highly curable if detected early and appropriately treated, certain types are particularly aggressive and have a propensity for invasion and metastasis.Slideshows, January 2018
The differential diagnosis for cysts in the neck includes congenital neck masses, metastatic squamous cell carcinoma, acquired laryngoceles, and cystic schwannomas. Congenital masses in the neck include branchial cleft cysts, thyroglossal duct cysts (TGDCs), ectopic thymus cysts, dermoid and teratoid cysts, cystic vascular abnormalities, and lymphatic malformations such as the cystic lymphangioma.Diseases/Conditions, Procedures, March 2017
Hodgkin lymphoma (formerly, Hodgkin disease) is a potentially curable lymphoma with distinct histology, biologic behavior, and clinical characteristics. The disease is defined in terms of its microscopic appearance (histology) and the expression of cell surface markers (immunophenotype).Diseases/Conditions, July 2017
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Authors
Eelam Aalia Adil, MD, MBA Attending Physician Department of Otolaryngology and Communication Enhancement
Boston Children's Hospital
Harvard University School of Medicine
Boston, MA
Disclosure: Eelam Aalia Adil, MD, MBA, has disclosed no relevant financial relationships.
David Goldenberg, MD, FACS Chief of Otolaryngology-Head and Neck Surgery Professor of Surgery and Oncology Pennsylvania State University College of Medicine; Director of Head and Neck Surgery Department of Surgery Division of Otolaryngology–Head and Neck Oncology Milton S. Hershey Medical Center Hershey, PA
Disclosure: David Goldenberg, MD, FACS, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS Clinical Associate Department of Diagnostic Radiology Duke University Medical Center Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Arlen Meyers, MD, MBA Professor Departments of Otolaryngology, Dentistry, and Engineering University of Colorado School of Medicine Denver, Colorado
Disclosure: Arlen Meyers, MD, MBA, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: MedVoy, Test Appropriate, Cerescan, Empirican PRN, and RxREVU.
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