EDWARD WEISBERGER MD
OTOLARYNGOLOGY/HEAD AND NECK
SURGERY
INDIANA UNIVERSITY MEDICAL CENTER
NECK MASS DIFFERENTIAL
DIAGNOSIS
• INFLAMMATORY (SUPPERATIVE
BACTERIAL INFECTION, INFECTED
BRANCHIAL CLEFT CYST,
GRANULOMATOUS-MYCOBACTERIAL,
CAT SCRATCH
• CONGENITAL-THYROGLOSSAL DUCT
CYST, LYMPHANGIOMA, DERMOID
CYST, BRANCHIAL CLEFT CYST,
TERATOMA
• NEOPLASM
AGE
• PEDIATRIC-INFLAMMATORY,
CONGENITAL
• TEENAGE-INFLAMMATORY,
LYMPHOMA, THYROID CA
• ADULT-METASTATIC SCC, THYROID
CANCER, LYMPHOMA
NEOPLASTIC (BENIGN)
• NEUROGENIC (NEUROLEMMOMA)
• VASCULAR (PARAGANGLIOMA OF
CAROTID BODY OR VAGAL BODY)
• VASCULAR (ANEURYSM)
• PAROTID (BENIGN MIXED TUMOR,
WARTHIN’S TUMOR)
• AYSYMETRICAL ENLARGEMENT OF
CERVICAL LYMPH NODES IN AN
ADULT ALWAYS DUE TO METASTASIS
FROM A HEAD AND NECK PRIMARY
(OFTEN SCC)
HAYES MARTIN 1952
NEOPLASTIC (MALIGNANT)
• METASTATIC SQUAMOUS CELL
CARCINOMA
• LYMPHOMA
• THYROID CANCER
• METASTATIC MELANOMA
• METASTIC TESTICULAR CANCER
CHARACTERISTICS OF A
METASTAIC NECK MASS
• PAINLESS
• UNILATERAL
• ADULT AGE GROUP
EVALUATION OF A NECK
MASS
• HX-HOARSNESS, DYSPHAGIA, PAIN
ORAL CAVITY, TOBACCO USE
• PE-EXAM OF ORAL CAVITY AND
OROPHARYNX DISCLOSES PRIMARY
50% OF TIME
• MIRROR OR FIBEROPTIC EXAM WILL
FIND THE PRIMARY IN AN ADDITIONAL
35%
ORAL CAVITY ULCERATIVE
LESION
FIBEROPTIC
LARYNGOSCOPY
FIBEROPTIC
LARYNGOSCOPY
FIBEROPTIC
LARYNGOSCOPY
EVALUATION OF A NECK
MASS
• LOCATION-UPPER NECK ANT. TO
SCM-MOST COMMON FOR H & N
PRIMARIES (SENTINAL NODE)
• POSTERIOR TRIANGLENASOPHARYNX
• SUPRACLAVICULAR-THYROID OR SITE
BELOW THE CLAVICLES
CAROTID BODY TUMOR
• LOCATED CAROTID BIFURCATION
• MORE DISCREET IN ANT/POSTERIOR
DIRECTION THAN
SUPERIOR/INFERIOR
• SOMETIMES A BRUIT
EVALUATION OF A NECK
MASS
• OFFICE BX. IF IN ORAL
• FNA-MIGHT DIRECT WORK-UP; IF
LYMPHOMA OR THYROID CANCER
• CT AND/OR PET SCAN
• EXAMINATION UNDER ANESTHESIAPALPATE TONGUE BASE, VISUALIZE
APEX OF PYRIFORM SINUS AND POSTCRICOID AREA
EVALUATION OF A NECK
MASS
• IF PRIMARY NOT IDENTIFIED AND
PATIENT HAS TONSILSTONSILLECTOMY WILL DISCLOSE A
PRIMARY IN 30% OF PATIENTS
TERATOMA
TERATOMA
LYMPHANGIOMA
LYMPHANGIOMA
VIRCHOW’S NODE
• LEFT SUPRACLAVICULAR NODE
REPRESENTING METASTASIS FROM
BELOW THE CLAVICLE-OFTEN FROM
BELOW THE DIAPHRAGM
VIRCHOW’S NODE
• AVOID ANTIBIOTIC THERAPY FOR A
PAINLESS NECK MASS IN AN ADULT
• EXAMINE ORAL CAVITY
• REFER FOR DEFINITIVE DIAGNOSIS
UNKNOWN PRIMARY
• MOST COMMON SOURCEHYPOPHARYNX, TONSIL, BASE OF
TONGUE
• IN PAST-NASOPHARYNX (MORE
COMMON IN CHINESE, AMERICAN
INDIAN, ALASKAN NATIVE)
UNKNOWN PRIMARY
HUMAN PAPILLOMA VIRUS
• INCREASINGLY COMMON ETIOLOGY
• EXPLAINS INCREASING INCIDENCE OF
SCC OF THE HEAD AND NECK IN NONSMOKERS
• INCREASED RISK OF HPV WITH
SEXUAL PROMUSCUITY
• ? VACCINATE YOUNG MALES