NECK MASS

Group 4 15/16

OUTLINE

• ANATOMY OF THE NECK• CLASSIFICATION OF NECK MASS• MAIN CAUSES OF NECK MASS

ANATOMY OF NECK

Neck is part of the bpdy between occipital and clavicle. Neck have more than 200 lymph node

Surface Anatomy

The prominent landmarks of the neck are:

• Hyoid bone • Thyroid cartilage• Cricoid cartilage• Trachea• Sternocleidomastoid

muscles

What forms the neck?

● Skin● Fascia of the neck

- Superficial cervical fascia- Subcutaneous fat- Platysma muscle- Superficial lymph node- Deep cervical fascia- Investing layer- Pretracheal layer- Prevertebral layer

● Muscles● Bone-cervical vertebral● Viscera of the neck● Neurovascular bundles● Lymphatic system

RETROPHARYNGEAL SPACE = Between the prevertebral fascia and the buccopharyngeal fascia

Triangles of the neck

-Submental (unpaired)-Submandibular (digastric)-Carotid-Muscular (omotracheal)

Posterior Triangles

Divided by inferior belly of the omohyoid ms into:

• Occipital• Supraclavicular

What is in your neck?Major triangles

Sub-divisions Content

Anterior Submental Submental LNSubmandibular Submandibular gland and LN,

hypoglossal n, mylohyoid n., parts of facial artery and vein

Carotid Carotid sinus and body, carotid sheath (IJV, CCA, vagus n.), ECA, hypoglossal n, ansa cervicalis (superior root), spinal accessory n., deep cervical LN, branches of cervical plexus, thyroid gland, larynx, pharynx

Muscular Infrahyoid muscles, thyroid and parathyroid glands

Major triangles

Sub-divisions Content

Posterior Occipital Transverse cervical artery, EJV, spinal accessory nerve, post branches of cervical nerve plexus, of brachial plexus, cervical LN

Supraclavicular Subclavian artery (3rd part), subclavian vein, suprascapular artery, supraclavicular LN

• NECK MASS = Defined as any abnormal enlargement, swelling or growth from the level of base of skull to clavicles

• Clinically neck masses can be divided into– Midline– Lateral (grouped according to triangles of the

neck)

CLASSIFICATION OF NECK MASS

Differential diagnosis according to positionMidline lumps - Dermoid cysts

- Thyroglossal cyst (moves on protruding lump)- Thyroid lump (moves on swallowing)- Lymphadenopathy

Lateral neck lumps1) SubmandibularTriangle

2) Anterior triangle

3) Posterior triangle

- Reactive lymphadenopathy (younger age group)- Neoplastic lymphadenopathy (firm, non-tender, older age group)- Submandibular gland disease (sialadenitis, sialolithiasis,neoplasm)

- Reactive lymphadenopathy or lymphoma (younger age group)- Specific infective adenopathy (TB, HIV toxoplasmosis, actinomycosis)- Neoplastic lymph adenopathy (firm, non-tender, lymphoma or squamous cell carcinoma)- Branchial cyst (2nd-3rd decades)- Thyroid masses (toxic goitre, cyst, neoplasm: benign or malignant)- Parotid gland disease (sialadenitis, cysts, sialolithiasis, neoplasm)- Paraganglioma (carotid body tumor, glomus vagale)- Laryngocoele (enlarges with blowing)-Cystic hygroma/lymphangioma

- Reactive lymphadenopathy (younger age group)- Neoplastic lymphadenopathy (firm, non-tender, older age group)- Lipoma

More common causes of neck swellingsClassification example of diseasesCongenital lymphangiomas, dermoids, thyroglossal

cysts

Developmental branchial cysts, laryngoceles, pharyngealSkin and subcutaneous tissue sebaceous cyst, lipomaThyroid swellings multinodular goitre, solitary thyroid

nodule

Salivary gland tumours pleomorphic adenoma, WarthinsTumours of the parapharyngeal space deep lobe parotid, chemodectoma

Reactive neck lymphadenopathy tonsillitis, glandular fever, HIV

Malignant neck node carcinoma metastases (unknownprimary), lymphoma

Age in relation to possible diagnosesChild(0–15 years)

Young adult( (16–35 years)

Adult(35 years +)

Congenital Cystic hygromaThyroglossalduct cyst

Branchial cyst Very uncommon

Inflammatory Very common Less common Rare

Salivary disease Inflammatory Sialolithiasis Neoplasms

Thyroid disease UncommonMalignancy

Papillarycarcinoma

Thyroid malignancy

Neoplasms Rare LymphomaSquamous cellcarcinomaMetastases

LymphomaMetastases

MAIN CAUSES OF NECK MASS

• BRANCHIAL CYST• THYROGLOSSAL DUCT CYST• THYROID CARCINOMA• GOITER• CAROTID BODY TUMOUR• NECK LYMPH NODES METASTASES

Branchial & Thyroglossal duct cyst

BRANCHIAL CYST

• Branchial cleft cysts are congenital epithelial cysts, which arise on the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development.

• Common in the 2nd decade of life but can occur at any age with equal frequency in both sexes.

Pathophysiology• At the 4th week of embryonic life, the development of 4

branchial (or pharyngeal) clefts results in 5 ridges known as the branchial (or pharyngeal) arches, which contribute to the formation of various structures of the head, the neck, and the thorax.

• The second arch grows caudally and, ultimately, covers the third and fourth arches. The buried clefts become ectoderm-lined cavities, which normally involute around week 7 of development.

• If a portion of the cleft fails to involute completely, the entrapped remnant forms an epithelium-lined cyst with or without a sinus tract to the overlying skin.

Clinical features• Swelling – upper part of neck, anterior to SCM• Mass – smooth, round, fluctuant, non-tender, non-

transilluminant• May be painful and increase in size at the time of URTI• Anomalies of the 2nd branchial arch are the most common• May be associated with a sinus or fistula

– External opening at the junction of lower and middle of the anterior border of sternocleidomastoid, may exude mucoid discharge

– Internal opening in the tonsillar fossa– If both external and internal opening present = branchial fistula

InvestigationsImaging• Sonogram

– If a sinus tract exists, radiopaque dye can be injected to delineate the course and to examine the size of the cyst.

• Ultrasonography– Delineate the cystic nature of these lesions.

• Contrast-enhanced CT scan– shows a cystic and enhancing mass in the neck. It may aid preoperative planning and identify

compromise of local structures.• MRI

– allows for finer resolution during preoperative planning. The wall may be enhancing on gadolinium scans.

Histopathological• Fine-needle aspiration

– May be helpful to distinguish branchial cleft cysts from malignant neck masses.– Fine-needle aspiration and culture may help guide antibiotic therapy for infected cysts.

Second branchial cleft cyst. Contrast-enhanced axial computed tomography scan

at the level of the hyoid bone reveals a large, well-defined, non-enhancing, water

attenuation mass (m) on the anterior border of the left sternocleidomastoid muscle(s).

First branchial cleft cyst, type II. Contrast-enhanced axial computed tomography scan at the level of the hyoid bone reveals an ill-defined, non-enhancing, water attenuation

mass (m) posterior to the right submandibular gland (g).

TreatmentMedical• Antibiotics are required to treat infections or abscesses related to branchial cleft

cysts.

Surgical• Surgical excision is definitive treatment for branchial cyst.• A series of horizontal incisions, known as a stairstep or stepladder incision, is made

to fully dissect out the occasionally tortuous path of the branchial cleft cysts.• Branchial cleft cyst surgery is best delayed until the patient is at least age 3 months. • Definitive branchial cleft cyst surgery should not be attempted during an episode of

acute infection or if an abscess is present.• Surgical incision and drainage of abscesses is indicated if present, usually along with

concurrent antimicrobial therapy.

THYROGLOSSAL DUCT CYST

• Thyroglossal duct cysts are the most common form of congenital neck cyst.

• The cyst is an epithelial remnant of the thyroglossal tract, and as such is composed of thick mucous material lined with secreting columnar or squamous epithelium. A thick fibrous capsule surrounds the cyst.

• TDC is found in between hyoid bone and the thyroid cartilage in about 60% of the patients, it is suprahyoid, supra-sternal and intra-lingual in about 24%, 13% and 2% respectively.

Moorthy, S. N., & Arcot, R. (2010). Thyroglossal Duct Cyst—More Than Just an Embryological Remnant. Indian Journal of Surgery Indian J Surg, 73(1), 28-31.

Pathophysiology• Thyroglossal duct cysts may arise during the 5th week of embryonic life after the

descent of the thyroid gland from the base of the tongue to its position in the neck.• The failure of the tract to involute by the 7th week results in the presence of a sinus

tract and cyst(s) in the midline of the neck.• If the lower part of the duct alone persists, it prevails as the pyramidal lobe of the

thyroid.• The foramen cecum, which typifies the ductal opening into the tongue, remains a

small blind pit in the mid line between the anterior two thirds and the posterior one third of the tongue.

• The cyst can occur anywhere along the thyroglossal duct tract from the foramen cecum at the base of the tongue to the level of the suprasternal notch.

• The cysts are most commonly located inferiorly to the hyoid bone within 2 cm of the midline with a close relationship to the hyoid, thyrohyoid membrane, or thyroid cartilage.

Karmakar S, Saha AM, Mukherjee D; Thyroglossal cyst: an unusual presentation. Indian J Otolaryngol Head Neck Surg. 2013 Jul;65(Suppl 1):185-7. doi: 10.1007/s12070-011-0458-5. Epub 2012 Jan 6.

Clinical features• Cystic midline swelling, usually affecting young children but can

occur at any age.• Usually rounded with a diameter of 2-4 cm.• May transilluminate – contains mucoid fluid or blood• Increases in size with URTI.• Sometimes it presents as a draining sinus if it has burst due to

infection or has been surgically drained.• Moves with tongue protrusion - it is attached to the thyroglossal

tract which attaches to the larynx by the peritracheal fascia.• (Rare) Can cause swallowing or breathing difficulty in neonates if

it is located at the base of the tongue.

InvestigationsImaging• Ultrasound

– unilocular lesions with thin walls and posterior acoustic enhancement.• CT scan

– The most helpful features in the differential diagnosis are the midline location, most often at or below the hyoid bone, and the intimate relationship of infrahyoid TDCs to the strap muscles.

– Can show capsular enhancement.– CT better evaluates the potential for thyroglossal duct carcinoma and is thus

preferred in adult patients.• MRI

– provides a high degree of diagnostic accuracy for TDC but it is rarely required for the diagnosis.

– Although TDCs are invariably hyperintense on T2-weighted images, T1-weighted signal intensity is variable.

Investigations

Investigations (cont)• Thyroid function test

– However, ectopic thyroid gland cannot be ruled out even in the presence of normal TSH levels and a clinically euthyroid history.

• Thyroid scanning– To demonstrate any functioning ectopic thyroid.– Ectopic thyroid tissue may accompany TGCs in their location

along the line of embryological thyroid descent.– This can also be used to demonstrate normal thyroid position

and function before removal of any thyroid tissue which may accompany the cyst.

Treatment

Complete surgical excision• Including with it the body of

hyoid bone and core of tongue tissue around the tract in the suprahyoid tongue base to the foramen caecum (Sistrunk’s operation).

• Simple excision of cyst without removal of its tract leads to recurrence.

Thyroid Carcinoma & Goitre

Neck Mass

~ Thyroid Gland ~

• Clinal approach once it is established that the neck swelling is indeed a thyroid swelling :

1) Diffuse enlargement : (a) Toxic ( Grave's disease) (b) Non toxic - other thyroiditis ( exp : Hashimoto thyroiditis , de Quervain's thyroiditis) - simple colloid goitre

2) Nodular enlargement : (a) Solitary nodule ( cyst , adenoma , neoplastic ) (b) Multinodular goitre ( toxic and non toxic )

https://www.slideshare.net/mobile/roger961/presentation-thyroid-swellings

Papillary Thyroid Carcinoma ( PTC )

• Papillary carcinoma (PTC) is the most common form of well-differentiated thyroid cancer, 75% to 85% and the most common form of thyroid cancer to result from exposure to radiation.

• 20-40 years of age• Aetiology : 1) Genetic factor : mutation in RET or NTRK1 / RAS , BRAF

oncogene,2) Exposure to ionizing radiation, particularly during 1st two

decades of life, especially head & neck region

Gross findings :

Histological findings : • •Branching papillae (fibrovascular stalk covered by

single to multiple layers of cuboidal epithelial cells)• •Diagnostic nuclear features → clear or empty

(ground glass or Orphan Annie eye nuclei) or intranuclear inclusion or intranuclear grooves

• •Psammoma bodies – concentrically lamellated calcified structures within the cores of papillae

• •Foci lymphatic invasion

History

• The most common presentation of thyroid cancer is an asymptomatic thyroid mass or a nodule that can be felt in the neck. For any patient with a thyroid lump that has developed recently, record a thorough medical history to identify any risk factors or symptoms. In particular, obtain a history regarding every prior exposure to ionizing radiation and the lifetime duration of the radiation exposure. Consider a family history of thyroid cancer.

• Some patients with thyroid cancer have persistent cough, difficulty breathing, or difficulty swallowing. Pain is seldom an early warning sign of thyroid cancer. Other symptoms (eg, pain, stridor, vocal cord paralysis, hemoptysis, rapid enlargement) are rare, and can be caused by less serious problems.

Physical Examination

The clinician should palpate the patient's neck to evaluate the size and firmness of the thyroid and to check for any thyroid nodules. The principal sign of thyroid carcinoma is a palpable nodule, usually solitary, in the thyroid area that has the following characteristics:• Painless • Hard consistency • Average size of less than 5 cm • Ill-defined borders • Fixed in respect to surrounding tissues • Moves with the trachea at swallowing

Investigations

• Thyroid function studies • TSH suppression test • Thyroid ultrasound • Fine-needle aspiration biopsy (FNAB)

• FNAB is considered the best first-line diagnostic procedure for a thyroid nodule.

Management • Surgery is the definitive management of papillary

thyroid cancer. Approximately 4-6 weeks after surgical thyroid removal, patients may have radioiodine therapy to detect and destroy any metastasis and residual tissue in the thyroid.

• External beam radiotherapy has been used as adjuvant therapy in patients with papillary thyroid cancer who were older than 45 years and had locally invasive disease. Some improvements in 10-year survival rates have been reported with this approach.

• Patients require lifelong thyroid hormone replacement therapy, especially after total thyroidectomy. Treatment consists of levothyroxine in a dosage of 2.5-3.5 mcg/kg/d.

http://emedicine.medscape.com/article/282276-overviewhttp://emedicine.medscape.com/article/2007769-overview

Goitre

• A goiter is an enlarged thyroid gland.• Classification : a) Simple goitre : - Diffuse hyperplastic - Multinodular goitre b) Toxic goitre : - Diffuse ( Graves disease ) - Multinodular - Toxic adenoma

History and Physical examination A goiter may present in various ways, including the following:• Incidentally, as a swelling in the neck discovered by the patient or on routine physical

examination • A finding on imaging studies performed for a related or unrelated medical evaluation • Local compression causing dysphagia, dyspnea, stridor, plethora or hoarseness • Pain due to hemorrhage, inflammation, necrosis, or malignant transformation • Signs and symptoms of hyperthyroidism or hypothyroidism • Thyroid cancer with or without metastases & proceeds to neck examination.

Simple goitre

Toxic goitre

Carotid body tumours and neck node metastases

Carotid body tumour

• Arises from the chemoreceptor cells in the carotid body a.k.a chemodectoma

• Mostly present after 40 y.o, very slow growing tumour

• About 5% of carotid body tumors are bilateral and 5-10% are malignant

Presentation

• Painless, pulsatile mass in the anterior triangle of the neck

• Bruit can be heard• Moves from side to side but not vertically (attachement

to bifurcation of carotid artery )• May extend into parapharyngeal space and present in

oropharynx• As the tumor enlarges and compresses the carotid

artery and the surrounding nerves - pain, tongue paresis, hoarseness, Horner syndrome, and dysphagia.

Investigation

• Simple ultrasonography with color Doppler – assess the vascularity of the neck mass

• Contrast-enhanced CT & MRI with gadolinium – Diagnostic & show extent of the tumor

• MRI angiography : splaying of internal & external carotid arteries— Lyre’s sign

• FNAC should not be done d/t vascularity of the tumor

Treatment

• Surgical remoral ( <50y/o or tumour extend to oropharynx causing difficult in speech, swallow/breathing)

• Radiotherapy (older pt, those unfit/refuse surgery/metastatic diseases)

Neck nodes

Posterior triangle 1) Occipital Transverse cervical a., occipital a., accessory nerve, posterior branches of cervical n. plexus, part of ext.jugular vein, cervical LN

2) Supraclavicular 3rd part of subclavian a., part of subclavian vein, suprascapular a.,vein, nerve, supraclavicular LN

Anterior triangle 1) Submental Submental LN

2) Submandibular Submandibular gland, duct, Submandibular LN, Hypoglossal nerve, Nerve to mylohyoid, Facial artery and vein, Submental artery

3) Carotid CCA and terminal branches, carotid sinus & body, carotid sheath (CCA,IJV, vagus n), ansa cervicalis, deep cervical LN, cervical part of sympathetic trunk, hypoglossal nerve

4) Muscular Infrahyoid muscle, thyroid and parathyroid gland

Lymph Nodes of Head & Neck

Lymph Nodes Level of NeckLevel Division

I Submental (1a)Submandibular (1b)

II Upper Jugular

III Mid Jugular

IV Lower jugular

V Posterior triangle group: Spinal accessory (Va)Transverse cervical chain (Vb)

VI PrelaryngealPretrachealParatracheal

VII Nodes of upper mediastinum

Lymph Nodes & Area of Drainage

Examination of nodes

• For head and neck malignancies• Systematic approach• Better palpated while standing at the back of

patient• Neck slightly flexed

• Upper horizontal chain (submental,submandibular,parotid,facial,postauricular and occipital nodes)

• External jugular chain (superficial to SCM)• Internal Jugular Chain (upper,middle and lower

groups)• Spinal accessory chain• Anterior Jugular chain• Juxtavisceral chain (level VI)

(Look for:location, number, size,consistency,discrete,tenderness,fixity)

Lymphadenopathy Neoplasm – Lymphoma• 1° malignant tumour of lymphatic tissues• Both Hodgkin’s & non- Hodgkin’s lymphoma• present with cervical lymphadenopathy

– Can occur at any age – Presents with painless, rubbery lymphadenopathy often in the

posterior triangle, & sometimes nodes in the axillae & inguinal areas.

– Systemic symptoms such as fever, night sweats, fatigue, and weight loss may occur, and hepatosplenomegaly is an associated finding

• Excision biopsy is often required to confirm dx

Tx : chemo- &/or radiotherapy

Secondary metastasis• Lymph node metastases usually present as a unilateral

progressive swelling of single or multiple nodes.• Any lymph nodes group can be involved depending on the site of

1° site of primary malignancy:1. Upper cervical LN :

o Commonly involved in malignancies of upper aerodigestive tract

2. Accessory chain of nodes in posterior triangle : o Nasopharyngeal malignancies

3. Nodes in supraclavicular area : o Possibility of an infraclavicular 1° in lung, breast,

stomach, colon, kidney, ovary & testis• Principle of management

• Identify primary lesion• Treat with combination of surgical excision, chemotherapy

and radiotherapy• Palliative care for terminal cases

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Inflammatory Disorders

• Lymphadenitis• Granulomatous lymphadenitis

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Lymphadenitis

• Very common, especially during 1st decade• Marked tenderness, torticollis, trismus, and

dysphagia• Systemic signs of infection• Initial treatment - directed antibiotics• Close follow up

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Lymphadenopathy

• Failure of antibiotics necessitates biopsy after complete head and neck work-up

• FNAC indications– Progressively enlarging nodes– Solitary, asymmetric nodal mass– Supraclavicular mass– Persistent nodes without infectious signs

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Granulomatous Lymphadenitis

• Develop over weeks and months• Minimal systemic complaints or findings• Firm glands, fixation and injection of skin• Common etiologies

– Typical Mycobacterium tuberculosis (adults)– Atypical Mycobacterium tuberculosis (children)– Cat-scratch fever (Bartonella henselae) (children)– Actinomycosis, Sarcoidosis

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Granulomatous Lymphadenitis

• Atypical TB– Anterior triangle lymph nodes– Induration and pain– Usually responds to complete surgical excision

• Typical TB (rarely seen, posterior nodes)

Patients with a clinical history of any of the following may be at risk for developing lymphadenitis:

• Symptoms of an upper respiratory tract infection, sore throat, earache, coryza, conjunctivitis, or impetigo

• Fever, irritability, or anorexia• Contact with animals, especially kittens or livestock• Recent dental care or poor dental health

• Physical examination findings suggestive of infection are as follows:• Soft• Fluctuant• Tender• Overlying erythema

Infectious agents/causes of lymphadenitis:

1. Bartonella henselae (catscratch disease) 2. Coccidioides immitis (coccidioidomycosis) 3. Cytomegalovirus4. Dental caries/abscess 5. Epstein-Barr virus (mononucleosis) 6. Francisella tularensis (tularemia) 7. Histoplasma capsulatum (histoplasmosis)8. Mycobacterium tuberculosis 9. Parvovirus 10.Rubella 11.Salmonella 12.Staphylococcus aureus adenitis 13.Group A streptococcal (GAS)

pharyngitis 14.Toxoplasma gondii 15.Viral pharyngitis16.Yersinia enterocolitica17.Yersinia pestis (plague)

InvestigationLaboratory studies are as follows :• Gram stain of aspirated tissue - To evaluate bacterial etiologies• Culture of aspirated tissue or biopsy specimen - To determine the causative organism

and its sensitivity to antibiotics• Monospot or Epstein-Barr virus (EBV) serologies - To confirm the diagnosis of

infectious mononucleosis• Bhenselae serologies - To confirm the diagnosis of catscratch disease (if exposed to

cats)• Skin testing or purified protein derivative (PPD) - To confirm the diagnosis of

tuberculous lymphadenopathy; alternative is interferon-gamma release assays (IGRA)• CBC count - Elevated WBC count may indicate an infectious etiology• Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) - Elevated ESR

and CRP are nonspecific indicators of inflammation• Liver function tests - May indicate hepatic or systemic involvement; elevated

transaminase levels can be seen in infectious mononucleosisImaging Studies• Ultrasonography may be useful for verifying lymph node involvement and taking

accurate measurements of enlarged nodes.

TreatmentTreatment depends on the causative agent and may include expectant management, antimicrobial therapy, or chemotherapy and radiation (for malignancy).

Neck dissection

• Radical neck dissection• Modified radical neck dissection• Selective neck dissection• Extended neck dissection

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