The etiology and differential diagnosis of neck masses is an important issue for otolaryngologists. Many patients from various clinics are referred or consulted with otolaryngologists. All diagnoses should be considered separately in each application of patients who apply for a neck mass.
A good anamnesis and a complete physical examination provide the greatest support in the evaluation of neck masses. A neck mass that grows and shrinks for a long time suggests congenital or inflammatory conditions (benign), while masses that are constantly growing and appear in a short time are more suggestive of malignancy.
The age of the patient is one of the important points in the anamnesis. The etiology of neck masses can be grouped according to age. In the pediatric group (0-18 years), a high rate of benign masses due to congenital and inflammatory conditions are seen (90%). In the adult group (>18 years old), malignant masses are seen at a higher rate (1).
Examination of other systems is also important in etiology. Related symptoms include dysphagia, fever, otalgia, weight loss, upper respiratory tract infection, hemoptysis, hearing loss, and respiratory distress.
Medical history and family history are important. The patient's immune status, family history of neck mass, radiation or inadequate surgery history are important in etiology.
After taking a detailed history, a detailed head and neck examination should be performed. Mobility, tenderness, location (anterior, lateral, supraclavicular), stiffness, fluctuation status, presence of erythema and relationship with other tissues of the mass are important in physical examination.
Detailed mucosal evaluation is made with a fiberoptic laryngoscope of the upper part of the respiratory and digestive system. Suspicious areas should be palpated and evaluated. Pathology may be in the submucosal area, therefore palpation of the floor of the mouth, tongue, buccal mucosa, palate, tonsils and root of the tongue is important.
Classification of neck masses:
There is a wide range of diseases in the differential diagnosis of neck masses (Table 1). When classifying neck masses, we can group them as anatomical localization, masses in pediatric and adult age groups, and classification of diseases. While congenital masses and reactive lymphadenopathies are frequently observed in the pediatric age group, malignant lesions are observed less frequently. Neck masses in children can be classified as anatomical region. Thyroglossal duct cyst and thyroid nodules are frequently observed in the midline anterior, while branchial cleft cysts, reactive lymphadenopathies and rarely lymphomas can be seen in the anterior sternocleidomastoid region. Lymphadeopathies and lymphadenitis from inflammatory and reactive lesions are frequently observed in the occipital, preauricular, submandibular and submental regions. Branchial cleft cysts in the preauricular region, parotitis, hemangiomas can be observed. In the pediatric age group, these diseases should definitely be examined more prominently (Table 2).
In the adult age group, various diseases can be considered in the differential diagnosis according to the duration of neck mass formation. Infection and traumatic conditions should be examined, especially in neck masses that occur in the acute period. Acute salivary gland infections, viral and bacterial agents causing reactive lymphadenopathy can be considered in the differential diagnosis. A history of trauma in the acute period is also important for the diagnosis of hematoma and pseudoaneurysm. In the differential diagnosis of neck masses occurring in the subacute period, we should consider malignant masses, systemic diseases, chronic sialoadenitis and idiopathic diseases. Chronic neck masses, on the other hand, may be associated with long-term symptoms such as congenital lesions, lipoma, and laryngocele, as well as malignant diseases such as thyroid nodules and cancer (Table 3). In the classification based on the diseases, the diseases are congenital,
We can basically classify neck masses in four different groups:
1) Congenital anomalies (vascular and non-vascular lesions)
2) Infectious or Inflammatory
4) Neoplastic lesions (Benign and malignant)
1) Congenital Anomalies
a: Vascular lesions
In the pediatric population, vascular lesions are included in tumors and malformations. Infantile hemangioma is the most common tumor in infants. These lesions are formed by proliferation of endothelial cells and are always found postnatally. It has three phases; 1) Rapid proliferation phase 2) Stable phase 3) Involution phase. The proliferative phase ends in 6-12 months. The stable phase follows this phase and the size of the hemangioma changes little in this phase. The involution phase begins around 24 months and complete regression is observed in 50% of patients around 5 years of age (2,5).
Vascular malformations are divided according to their high and low hemodynamic flow. Arteriovenous malformation and arteriovenous fistula have arterial and venous connections and are high-flow lesions. Cosmetic problems, ischemic ulcers and congestive heart failure may occur. MTA and CTA are good methods in the evaluation of these lesions (2).
Slow flow malformations are venous malformations and lymphatic malformations. Venous malformations arise from dysplastic venous ducts. It appears blue and purple and is detected as spongy on palpation. It enlarges frequently with the Valsalva maneuver and is easily differentiated from lymphatic malformations with MRA (2). Lymphatic malformations are hamartomatous lymphatic vessels. It is often present at birth, does not resemble hemangioma, is the second most common soft tissue mass in newborns. It is divided into two as microcystic (<1cm) and macrocystic (>1cm). It can occur anywhere in the neck, but is most common in the posterior triangle. The best radiological examination is MRI.
b: Nonvascular lesions
Thyroglossal duct cyst:
The most common congenital neck mass in children is thyroglossal duct cyst (70%). The thyroglossal duct cyst originates in the embryonal tract of the thyroid gland, at the junction of the oral and oropharyngeal tongue. It is located in the anterior neck (2,5). It is usually below the hyoid bone, but can also be above the hyoid bone. On physical examination, the thyroglossal duct cyst is often palpated as soft and cystic, and when the tongue is protruded, it rises vertically upward on the neck. It can be infected and detected as an inflammatory neck mass. These lesions may include thyroid tissue and malignancy. Presence of functional thyroid tissue before excision should be evaluated with thyroid function tests, USG and radionuclide scanning.
Branchial cleft cyst:
Branchial cleft anomalies are frequently found in the pediatric population. It is the second most common after thyroglossal duct cyst. It consists of embryonal branchial tissues that have undergone incomplete obliteration. The most common 2nd branchial arch anomaly is seen (95%) (2,6). Cystic mass or drainage tract is frequently seen in front of the sternocleidomastoid muscle, the tract ends in the tonsillar fossa above the lateral of the internal carotid artery. Rarely, malignancy may develop from the epithelium of the cyst.
First branchial arch anomalies are 1% of all branchial arch anomalies and can be classified as type 1 and type 2. Type 1; It is associated with the external auditory canal and skin. Type 2; it is within the parotid gland and deep to the facial nerve (6).
Third and fourth arch anomalies are very rare. The third arch anomaly proceeds medial to the internal carotid artery, pierces the thyrohyoid membrane and opens into the piriform sinus. It is often above the superior laryngeal nerve. The fourth arch anomaly is deep in the subclavian artery on the right and below the aortic arch on the left. As a result, it enters the pyriform sinus, is below the superior laryngeal nerve, and may be associated with the thyroid gland (2,6).
Ranula is a mucocele and retention cyst. It occurs due to sublingual gland obstruction. Deep in the mylohyoid muscle, it is called plunging ranula . Clinically, it is seen as a neck mass associated with the floor of the mouth at level I. USG, CT and MRI can easily distinguish these lesions(2).
Teratomas are neonatal neck masses that contain all 3 germ layers. It is frequently diagnosed prenatally. Calcification is detected in soft tissue, cyst and adipose tissue imaging. Calcification in the neck mass is often suggestive of teratoma. It can be seen as a rapidly growing neck mass in newborns. Intubation or in utero intervention may be required for airway support (2).
Unlike teratoma, dermoid cysts contain 2 germ layers (ectoderm, endoderm). It is often seen in the midline of the neck or slightly lateral to the midline. It is often seen before 3 years of age.
2) Inflammatory and Infectious Masses
Inflammatory and infectious masses are the most common neck masses in adults and children. The face, upper respiratory tract, upper part of the digestive tract primarily drains into the neck lymphatic system. Reactive nodes on the neck are detected as palpable, mobile, sensitive. Fever, upper respiratory tract infection, toothache, dysphagia may be found in the anamnesis. If the node becomes necrotic and abscessed, there will be tenderness on palpation. Fluctuation can be taken according to the state of necrosis and inflammation. Abscess can be easily evaluated with USG and CT(7). If an abscess is present, incision and drainage are required in addition to antibiotics. If the lesion does not regress in a few weeks, different diagnoses should be considered.
Sialoadenitis and sialolitiasis:
Major salivary gland obstructions at levels I and II cause secondary infection. There is often mechanical obstruction (sialolithiasis). It may be in functional obstruction due to dehydration in the elderly population. Malignancy originating from the floor of the mouth may cause unilateral swelling of the submandibular gland by causing obstruction in the Wharton duct. Salivary gland duct obstruction is easily evaluated with USG. CT can also be taken if needed. If a stone is detected in the canal, it is encouraged to throw away the stone with massage. Hydration and salivary stimulants are indicated. If conservative approaches fail, the stone or gland is surgically excised.
Granulomatous inflammatory diseases:
Many granulomatous diseases may present in the form of cervical lymph nodes. Examples are sarcoidosis, tuberculosis, toxoplasmosis, actinomatosis, fungal infection, brucellosis, cat scratch disease and kawasaki disease. FNAB is performed for cytopathological sampling. Excisional and incisional biopsy are tried last because it causes chronic discharge.
Hematoma may occur after intramuscular hemorrhage after trauma in adults during delivery in pediatric cases. Clinically, it presents as an organized swelling in the neck. It usually resolves spontaneously, but it can cause torticollis in the pediatric age group.
These masses, which may occur after penetrating and blunt trauma to the neck, can be life-threatening. These masses formed after trauma can be followed up with close follow-up if the patient's clinic is stable. If there is a clinical deterioration, the mass should be intervened with an endovascular or neck approach.
Neoplasms in the neck arise from primary head regional metastases, from visceral structures or distant metastases from the skin, or from the internal structures of the neck itself.
Thyroid gland neoplasms occur in the anterior or lateral neck and may metastasize to the jugular lymph nodes. Although nodule in the thyroid gland is more common in women, it affects both sexes as age increases. The vast majority of thyroid nodules are benign, only 10% are malignant (9). Thyroid nodules can be easily examined with USG, and FNAB is performed with USG for cytopathological examination.
Salivary gland neoplasms:
Salivary gland-derived neoplasms are predominantly parotid and 15-20% submandibular in origin. 80% of parotid neoplasms are benign, 50% of submandibular gland neoplasms are malignant (10). While salivary gland neoplasms are frequently seen in adults, the possibility of malignancy increases if they are seen in children. These neoplasms are often evaluated with CT or MRI. MRI is particularly good for the evaluation of soft tissue anatomy and perineural invasion. Pathological lymph nodes can also be easily evaluated with these methods. FNAB, one of the detected lesions, is also important in surgical planning (11).
Cervical lymph nodes carry the potential for primary lymph node malignancies. Lymphoma is the most common type of head and neck malignancy in the pediatric population. It is the second most common type in adults. Lymphomas are divided into Hodgkin lymphoma and Non-Hodgkin lymphoma. Non-Hodgkin lymphoma has a higher incidence in the head and neck. B-cell subtype is the most common of the cervical non-Hodgkin lymphomas (12).
Neurogenic neoplasms may be schwannoma (most common), neurofibroma, malignant peripheral nerve sheath tumor, neuroblastoma, and ganglioneuroblastoma. Schwannomas often occur as a parapharyngeal mass in adults. It arises from the cranial nerves, spinal nerves, or sympathetic trunk. CT and MR (better) can be used in radiological diagnosis. Its classic finding is anterior displacement of carotid sheath contents. The use of FNAB is often low because cytological findings are also present in other soft tissue tumors.
Neuromas are caused by trauma or damage during surgery. Patients often present with a painful neck mass. It is frequently found after sacrification of the nerve auricularis magnus after parotidectomy.
The most common subcutaneous neoplasm in adults is lipoma. It is benign and often painless. It can occur anywhere in the neck, but is most common in the posterior.
Occult Regional Metastatic Squamous Cell Carcinoma
Squamous cell carcinoma metastasis of unknown primary can be detected in the neck. Often patients have no or minimal symptoms. Neck metastases of unknown primary cause 2-9% of all head and neck malignancies (4,14). 90% of these are SCC, and there may be adenocarcinoma, melanoma and other rare malignancies.
Physical examination is important because submucosal lesions may not be detected on rapid or sloppy examination. Root of tongue, tonsils, nasopharynx are areas where occult lesions can occur.
The diagnosis of metastatic disease should be confirmed by performing FNAB from the nodes in the neck. The most important thing after diagnosis is imaging. PET-CT has become the most important modality in the evaluation of related fields. PET-CT is useful to evaluate not only metastatic disease but also the proximal aerodigestive system that may cause neck disease.
After PET-CT, diagnosis is made by endoscopy, laryngoscopy and direct biopsies. Biopsy should be done from suspected areas on PET. If there is no suspicious area in PET or physical examination, nasopharyngeal biopsy, tongue root biopsy, ipsilateral tonsillectomy are performed.