Differential Diagnoses of Neck Masses

1. EVALUATION OF THE NECK
Frederick Mars Untalan MD

2. Lymphoma
 More common in children
and young adults
 Up to 80% of children with
Hodgkin’s have a neck
mass
 Signs and symptoms
 Lateral neck mass only
(discrete, rubbery,
nontender)
 Fever
 Hepatosplenomegaly
 Diffuse adenopathy

3. Lymphoma
 FNAB – first line diagnostic test
 If suggestive of lymphoma – open biopsy
 Full workup – CT scans of chest, abdomen,
head and neck; bone marrow biopsy

4. Salivary Gland Tumors
 Enlarging mass
anterior/inferior to ear
or at the mandible
angle is suspect
 Benign
 Asymptomatic
except for mass
 Malignant
 Rapid growth, skin
fixation, cranial nerve
palsies

5. Salivary Gland Tumors
 Diagnostic tests
 Open excisional biopsy (submandibulectomy or
parotidectomy) preferred
 FNAB
 Shown to reduce surgery by 1/3 in some studies
 Delineates intra-glandular lymph node, localized
sialadenitis or benign lymphoepithelial cysts
 Accuracy >90% (sensitivity: ~90%; specificity: ~80%)
 CT/MRI – deep lobe tumors, intra vs. extra-parotid
 Be prepared for total parotidectomy with possible
facial nerve sacrifice

6. Carotid Body Tumor
 Rare in children
 Pulsatile, compressible mass
 Mobile medial/lateral not
superior/inferior
 Clinical diagnosis, confirmed by
angiogram or CT
 Treatment
 Irradiation or close observation in the
elderly
 Surgical resection for small tumors in
young patients
 Hypotensive anesthesia
 Preoperative measurement of
catecholamines

7. Carotid paragangliomas

8. Carotid paragangliomas
 Treatment
 Surgery
 Mortality 8%, >5cm tumors had more
complications
 Preop workup key – vascular surgeon,
anesthesia
 Embolization – controversial
 Radiation

9. Vagal paragangliomas
 Most commonly at nodose ganglion
 Painless mass at angle of mandible present
for many years – enlarging may get Horner’s,
CN XII, hoarseness
 More multicentric (25%)
 Malignancy (18%)
 None produce catecholamines

10. Vagal paragangliomas

11. Lipoma
 Soft, ill-defined
mass
 Usually >35 years
of age
 Asymptomatic
 Clinical diagnosis
– confirmed by
excision

12. Neurogenic Tumors
 Arise from neural crest derivatives
 Include schwannoma, neurofibroma, and
malignant peripheral nerve sheath tumor
 Increased incidence in NF syndromes
 Schwannoma most common in head &
neck

13. Schwannoma
 Sporadic cases mostly
 25 to 45% in neck when
extracranial
 Most commonly between 20 and
50 years
 Usually mid-neck in poststyloid
compartment
 Signs and symptoms
 Medial tonsillar displacement
 Hoarseness (vagus nerve)
 Horner’s syndrome
(sympathetic chain)

14. Congenital & Developmental Mass
 Epidermal and sebaceous cysts
 Branchial cleft cysts
 Thyroglossal duct cyst
 Vascular tumors

15. Epidermal and Sebaceous Cysts
 Most common
congenital/developme
ntal mass
 Older age groups
 Clinical diagnosis
 Elevation and
movement of overlying
skin
 Skin dimple or pore
 Excisional biopsy
confirms

16. Branchial Cleft Cyst
 2nd cleft most common
(95%) – tract medial to
cnXII between internal
and external carotids
 1st cleft less common –
close association with
facial nerve possible
 3rd and 4th clefts rarely
reported
 Present in older children
or young adults often
following URI

17. Branchial Cleft Cyst
 Most common as smooth,
fluctuant mass underlying
the SCM
 Skin erythema and
tenderness if infected
 Treatment
 Initial control of infection
 Surgical excision,
including tract
 May necessitate a total
parotidectomy (1st cleft)

18. Thyroglossal Duct
Cyst
 Most common congenital neck
mass (70%)
 50% present before age 20
 Midline (75%) or near midline
(25%)
 Usually just inferior to hyoid
bone (65%)
 Elevates on
swallowing/protrusion of tongue
 Treatment is surgical removal
(Sistrunk) after resolution of any
infection

19. Thyroglossal Duct Cyst
 Most common congenital midline mass
 Ectopic thyroid tissue vs. thyroglossal duct cyst
 Asymptomatic mass at or below the hyoid bone
that elevates with tongue protrusion.
 Ultrasound
 Thyroid Scan in patients that do not
demonstrate a normal thyroid by US.

20. Vascular Tumors
 Lymphangiomas and hemangiomas
 Usually within 1st year of life
 Hemangiomas often resolve spontaneously
 lymphangiomas remain unchanged
 CT/MRI may help define extent of disease

21. Vascular Birthmarks
 Classification system
 Hemangioma vs. malformation
 Based on clinical, cellular, biologic factors
 Older terms – “capillary”, “juvenile”, “strawberry”,
“cavernous”

22. Vascular
Birthmarks

23. Hemangiomas
 Most common
tumor of infancy
(10%)
 Slight female
predominance
 60% arise in head
and neck – cosmetic
concerns

24. Hemangiomas
 Clinical presentation
for diagnosis
 Not seen at birth
 Precursor lesion
 Proliferative phase
 Involution phase
 Superficial vs. deep

25. Complications from Hemangiomas
 Occur in 20%
 Ulceration
 Compression of vital structures
 High-output cardiac failure
 Bleeding
 Kasabach-Merritt
syndrome

26. Laryngeal Hemangiomas
 Usually in the
subglottis
 Healthy infant with
biphasic stridor
(croup)
 Behave similarly
 50% with cutaneous
counterpart

27. Treatment of Hemangiomas
 Why and when to treat?
 Normal skin in 50%
that involute within 5
years
 Other 50%-- 80%
substantial deformity
 Pro’s and Con’s

28. Treatment of Hemangiomas
 Observation
 Serial photography important to document
involution
 Regular visits with reassurance

29. Treatment of Hemangiomas
 Systemic steroids
 Careful selection criteria
 Prednisone 2-4mg/kg for up to 6 weeks
 Varied results (30%)
 Side effects

30. Treatment of Hemangiomas
 Intralesional
steroids
 Usually for
vision
threatening
lesions
 Combination
of beta-
methasone
and
triamcinolone

31. Treatment for Hemangiomas
 Surgery
 Eyelid lesions, bulky
lesions, vermillion
border, nasal tip,
eyebrow
 CO2 laser for
subglottis
 Arterial embolization
 Radiation therapy
 Alpha-2b interferon

32. Vascular malformations
 Capillary, venous, arterial, lymphatic, mixed
 By definition– present at birth
 No proliferative or involution phase
 Commensurate growth

33. Capillary malformations
 Older term– “port-
wine stain”
 Usually in
trigeminal
distribution
 Most isolated
anomalies
 Sturge-Weber
syndrome

34. Treatment of Capillary
Malformations
 Cosmetic concealing
makeup
 Tattooing
 Surgical excision
(tissue expanders)
 Pulse dye-laser

35. Venous Malformations
 Diagnosis is clinical – palpation
 Treatment dependent on location (surgery
and sclerotherapy)

36. Vascular Tumors
(lymphangioma)
 Older terms–
“cystic hygroma”,
“lymphangioma”
 Can expand with
URI
 Surgical
treatment is
mainstay
 Picibanil
(OK-432)

37. Arteriovenous malformations
 Usually clinically apparent
 Embolization and surgical resection

38. Nasopharyngeal Angiofibroma
 Most common benign tumor of nasopharynx
 Older term– “juvenile nasopharyngeal
angiofibroma”, “JNA”
 Presentation: recurrent epistaxis/nasal
congestion, hearing loss, orbital, CN
 Arise where sphenoidal process of palatine
bone meets horizontal ala of vomer

39. Nasopharyngeal Angiofibroma
 Diagnosis is made by
clinical and
radiographic findings
 CT/MRI
 Biopsy- rarely
indicated
 Angiography

40. Nasopharyngeal Angiofibroma
 Angiography Histology

41. Nasopharyngeal Angiofibroma
 Treatment
 Embolization and surgery
 Autologous blood/Cell Saver
 Approaches
 Transnasal endoscopic, lateral
rhinotomy/MFD with medial maxillectomy or
LeFort I, transpalatal, facial
translocation/maxillary swing, infratemporal
approaches, craniotomy
 Radiation therapy
 Chemotherapy

42. Malignant Vascular Tumors
 Angiosarcoma
 Extremely rare (50% in
head and neck)
 Prognosis on tumor size,
grade, margins
 Radiation minimally
effective
 Sinonasal tract less
aggressive
 Poor survival

43. Malignant Vascular Tumors
 Hemangiopericytoma
 Pericytes of
Zimmerman
 25% in head and neck
 Surgical treatment
 Grade important on
prognosis
 Radiation/chemotherap
y for selected cases

44. Malignant Vascular Tumors
 Kaposi’s Sarcoma
 Viral-induced
 Four entities
 Classic
 Endemic
 Immunosuppressed
 AIDS-related
 Surgery, chemo, radiation,
sclerotherapy

45. Paragangliomas
 Named for anatomic location
 Arise in paraganglionic tissue (neural crest)
 Type I cells (chief) – APUD cells – catecholamines
 Type II cells (sustentacular)
 Clusters together– “Zellballen”
 Malignancy is clinical

46. Cervical Thymic Cysts
 Failure of involution of the cervical
thymopharyngeal ducts.
 Firm, mobile masses found in the lower
aspects of the neck.
 CXR, CT scan

47. Dermoid Cysts
 Mesoderm and Ectoderm
 Midline, paramedian, painless masses that
usually do not elevate with tongue
protrusion.
 Commonly misdiagnosed as Thyroglossal
Duct Cysts.
 Treatment is simple surgical excision

48. Teratoid Cysts and Teratomas
 All three germ cell layers- Endoderm,
mesoderm and ectoderm.
 Larger midline masses, present earlier in life.
 20% associated maternal polyhydramnios
 Unlike adult teratomas, they rarely
demonstrate malignant degeneration.
 Surgical excision.

49. Laryngoceles
 Congenitally from an enlarged laryngeal
saccule.
 Classified as internal, external, or both
 Internal
 Confined to larynx, usually involves the false cord
and aryepiglottic fold.
 Hoarseness and respiratory distress vs. neck mass.

50. Plunging Ranula
 Simple ranula- unilateral oral cavity cystic lesion.
 Plunging ranula- pierce the mylohyoid to present
as a paramedian or lateral neck mass.
 Cyst aspirate- high protein, amylase levels
 CT scan/MRI
 Treatment is intra-oral excision to include the
sublingual gland of origin.

51. Sternomastoid Tumor of
Infancy
 Firm mass of the SCM,
(Pseudotumor) chin turned away and
head tilted toward the mass.
 Hematoma with subsequent fibrotic
replacement.
 Ultrasound
 Physical therapy is very successful.
 Myoplasty of the SCM only if refractory to PT.

52. Infectious and Inflammatory
Lesions
 40% of infants have palpable LAD
 55% of pediatric patients.
 Most commonly involving the submandibular
and deep cervical nodes.

53. Lymphadenitis
 Very common, especially within 1st decade
 Tender node with signs of systemic infection
 Directed antibiotic therapy with follow-up
 FNAB indications (pediatric)
 Actively infectious condition with no response
 Progressively enlarging
 Solitary and asymmetric nodal mass
 Supraclavicular mass (60% malignancy)
 Persistent nodal mass without active infection

54. Lymphadenopathy
 Equivocal or suspicious FNAB in the pediatric
nodal mass requires open excisional biopsy to
rule out malignant or granulomatous disease

55. Granulomatous lymphadenitis
 Infection develops over weeks to months
 Minimal systemic complaints or findings
 Common etiologies
 TB, atypical TB, cat-scratch fever, actinomycosis,
sarcoidosis
 Firm, relatively fixed node with injection of
skin

56. Granulomatous lymphadenitis
 Typical M. tuberculosis  Atypical M. tuberculosis
 more common in  Pediatric age groups
adults
 Anterior triangle
 Posterior triangle nodes
nodes
 Brawny skin,
 Rarely seen in our
population induration and pain
 Usually responds to  Usually responds to
anti-TB medications complete surgical
 May require excisional excision or
biopsy for further curettage
workup

57. Granulomatous
lymphadenitis
 Cat-scratch fever
(Bartonella)
 Pediatric group
 Preauricular and
submandibular nodes
 Spontaneous resolution
with or without
antibiotics

58. Bacterial Cervical Adenitis
 Tender, enlarged nodes
 Organisms- Staphylococcus, Group A
Streptococcus
 Treatment- Beta-lactamase resistant
antibiotic
 Fine Needle Aspiration

59. Viral Adenitis
 Most common infectious process in the neck.
 Rhinovirus, adenovirus, enterovirus.

60. Summary
 Extensive differential diagnosis
 Age of patient is important
 Accurate history and complete exam essential
 FNAB – invaluable diagnostic tool
 Possibility for malignancy in any age group
 Close follow-up and aggressive approach is
best for favorable outcomes