A detailed anamnesis is the first step for diagnosis in neck masses. Complaints concerning the head and neck region such as whether the mass is congenital, duration, sudden growth, pain, sore throat, earache, upper respiratory tract infection, tooth complaints, hoarseness, shortness of breath, difficulty in swallowing, as well as fever, night sweats, systemic symptoms such as weight loss should be asked.
In addition, the patient's social level, alcohol, smoking habits, recent travel should be questioned(1)
When evaluating a patient with a neck mass, the age group should be considered first. It can be grouped as pediatric(15 years old and under), young adult(16-40 years old), adult(over 40 years old). Congenital, inflammatory and neoplastic diseases should be kept in mind for each group.
In pediatric patients, inflammatory neck masses are generally more common than congenital and developmental ones, and neoplastic masses are the least common. This incidence is similar in young adults. In adults, neoplastic masses are the most common, inflammatory second, and congenital masses are less common.(2)
The patient is asked whether he has received any previous treatment with the same complaints, his history of surgery or radiotherapy.
In adults, research is done to determine whether the mass is benign or malignant. Malignancy is common in smokers over the age of 40. (3)
Localization of the mass, size, mobility, consistency, shape, surface, relation to the surrounding tissues, depth, sensitivity, color and temperature change in the skin, presence of trill or pulsation should be evaluated and noted with inspection and palpation.
A complete head and neck examination should be performed. The relationship of the mass with the thyroid gland, parotid and submandubular gland should be evaluated. Endoscopic examination of the ear and its surroundings, face and neck skin, nose, nasopharynx, oropharynx, oral cavity, teeth, hypopharynx and larynx should be performed. Infections and tumoral lesions in these regions may cause lymph adenopathy in the neck.
In addition, malignant masses of the lung, breasts, lymphoma, gastrointestinal system, uterine cervix, ovary and pancreas can metastasize to the supraclavicular region, especially in the head and neck region.
In general, a careful physical examination gives a general opinion of the source of the mass, such as vascular, cystic, nodal, inflammatory, congenital, or neoplastic, but does not make a definitive diagnosis. Many tests are helpful at this point.
Imaging techniques are one of the most helpful methods in a patient with a neck mass. In general, plain radiographs are not very helpful in the diagnosis of neck mass.
USG : When ultrasound is used in addition to or instead of CT, it is useful to distinguish solid lesions from cystic lesions, and to see the difference between low and high flow in mass width and vascular malformations(4). Likewise, USG is used as a guide for fine needle aspiration biopsy (FNAB) in nonpalpable or small superficial lesions. Although USG and CT have similar indications, USG may be preferred to reduce radiation exposure in young patients. Likewise, USG is preferred in patients with renal disease to avoid contrast medication that triggers nephropathy(4).
USG is helpful in distinguishing congenital branchial and thyroglossal cysts from solid lymph nodes, neurogenic tumors and ectopic thyroid tissue. When both A-mode and B-mode scanners are used, the accuracy of USG in distinguishing solid and cystic lesions is between 90-95%(2).
Radionuclide examination, sialography and ultrasonography are valuable for salivary gland lesions. A radionuclide scan or sialogram usually shows whether the mass is inside or outside the salivary gland. Radionuclide scan shows whether the mass is functional or non-functional.
CT in neck evaluation ; While its widespread availability, short extraction time, good evaluation of bone structures, reliability in demonstrating lymph node involvement, and less artifacts, create advantages such as low soft tissue resolution, exposure to radiation, tumor-related tissue thickening, and tissue destruction.
Imaging selection for adenopathy or neck mass in adults according to the American Society of Radiology; Contrast-enhanced CT is preferred in nonpulsatile solid or multiple masses, contrast-enhanced CT and CT angiography in pulsatile neck mass, and contrast-enhanced CT or PET in neck mass with cancer treatment history(3).
MRI is more effective in demonstrating neck soft tissue infiltration. Especially the fact that there are two basic sequences and the lesions show different behavior patterns in these secants are extremely useful in making the diagnosis. However, due to the length of the shooting period, some patients have difficulty in cooperation and it becomes impossible in patients with claustrophobia.
MRI seems to be superior to CT in distinguishing pathological conditions in soft tissue, detecting central necrosis in metastatic nodes, and detecting irregularities in soft tissues. In one study, MR sensitivity and specificity were found to be 65% and 81% in the evaluation of neck lymph nodes (5). The most reliable imaging finding in metastatic lymph node is the presence of nodal necrosis. Central necroses larger than 3 mm can be routinely seen on contrast-enhanced CT scans. CT is a better method than MR in demonstrating capsule penetration and extracapsular nodal extension. While CT showed 84% negative and 50% positive predictive value in showing a 1 cm size or a positive node with central pathology criteria, 79% negative and 52% positive predictive values were found with MRI(6) However, CT in residual metastatic diseases,
PET-CT is a new radionuclide scan method that shows the functional activity of the mass. It is quite expensive compared to other imaging methods. However, it is seen as more advantageous than other imaging methods in cases such as lesion prevalence, invasion into surrounding tissues, tumor staging, treatment planning, evaluation of the result and recurrence. In addition, it provides valuable results in the detection of distant metastases, determination of response to treatment, radiotherapy planning and prognosis (7).
It is important whether sudmax measurement with PET CT is significant in the evaluation of lymph node metastasis in the neck. LAP-sudmax cutt-off point was calculated in a study we conducted for our assistant's thesis. The cut-off point was found to be 3.2 using ROC analysis and screening tests (8). In terms of lymph node metastasis, above 3.2 sud max value is significant. Lymph node sudmax values of poorly differentiated cases were found to be higher than well-differentiated cases.
In the study of Kim et al., the sensitivity of CT/MR in detecting lymph node metastasis in patients with laryngeal carcinoma was 42%, and the specificity was 88%; On the other hand, PET-CT has a sensitivity of 58% and a specificity of 90%.(9). Although PET has been recommended as the method of choice in the investigation of lymph node spread in head and neck cancers, it should be kept in mind that false positive 18-FDG uptake can sometimes be observed in inflammatory lesions as well.( 10)
As a result of all these studies and evaluations, the imaging method of first choice in the evaluation of a neck mass should be CT with contrast.
A definitive diagnosis could not be made by examination, but in a patient who was thought to have inflammatory adenopathy, an antibiotic treatment not exceeding two weeks was accepted by clinical tests. If the mass does not shrink or continues to grow despite antibiotic treatment, additional examinations are required (11).
Laboratory tests to be done:
-Complete blood count: Serious systemic diseases, leukemia, infectious mononucleosis
-Sensitivity cultures: In inflammatory tissues from open biopsy
-Skin tests, PPD: Tuberculosis, atypical tuberculosis
-Viral titrations: Inflammatory masses that do not respond to antibiotics or those with suspected viral infection in the anamnesis (Ebstein bar virus, Cat scratch disease, Stylomegalovirus, HIV, Toxoplasma)
Acute rapidly growing masses are usually inflammatory. If the mass persists for more than 6 weeks or continues to grow despite antibiotics, neoplastic should be considered.
Fever, rapid growth, tenderness suggest inflammatory etiology. Likewise, acute infection may occur in a necrotic malignant lymph node.
An upper respiratory tract infection can cause reactive cervical lymphadenopathy. Secondary infection may develop in a congenital cyst. In a case treated with a preliminary diagnosis of TB. lymphadenitis, an epidermoid cyst was diagnosed after excisional treatment(12).
High fever, bilateral conjunctivitis, strawberry tongue and lymphadenopathy accompanying oral mucosal changes are seen in Kawasaki disease.
Recent URTI, animal contact (cat scratch, feces, flying animals), tick bite, contact with a patient with tuberculosis, travel abroad, exposure to ionizing radiation should be reviewed. Drug intake, such as Phentoin(dilantin), may cause pseudo lymphoma or adenopathy (Anticonvulsant hypersensitivity syndrome).(13).
Laterally located lymphadenopathies can be inflammatory or neoplastic. 1 cm up to 12 years old. sized lymph node is normal, it can enlarge up to 1.5 cm in the jugulodigastric region. A biopsy is recommended for persistent adenopathies larger than 2 cm that do not shrink with medication.
Biopsy and pathological examination are the definitive diagnostic tests preferred in neck masses. Fine-needle aspiration biopsy (FNAB), which is a noninvasive, cost-effective method, is primarily preferred in order to avoid open biopsy and to obtain critical diagnostic information. With an experienced cytopathologist, the accuracy rate of FNAB in the neck is 95%(14). Gram stain, bacterial and acid bacillus cultures are performed by cytology. The sensitivity of FNAB in detecting malignancy is 77-97%, and its specificity is between 93-100%.(3)
Micro-sized tissue taken by FNAB is sufficient for flow cytometry for lymphoma diagnosis and polymerase chain reaction (PCR) for Ebstein-Barr (EBV) detection for primary nasopharyngeal cancer. FNAB is helpful in differentiating carcinoma from lymphoma in adult patients. USG or CT-guided FNAB is performed in small or deep masses that are not palpable. In cases where a definitive diagnosis cannot be made with FNAB or lymphoma, open biopsy may be required for type determination.