Evaluation and Management of the
Patient with a Neck Mass
Bastaninejad, Shahin, MD,
and HNS Specialist
ORL
Anatomy
History and P.Exam.
Historical Points
• Age:
– Up to 15yrs (pediatrics)  more than 90% benign
– 16 to 40 (young adult)
– More than 40yrs (older adults)  80% neoplasm 
80% of them malignant (secondary>>primary)
• Time course
• immunodeficiency
• Prior trauma
• Travel, Irradiation, Surgery
• Associated symptoms  fever, dysphagia, weight
loss, otalgia, hearing loss, respiratory difficulties
• Perform a FULL head and neck examination
Diagnostic imaging
Table 116-1 -- Imaging of Neck Masses
Modality
Basic Indications
Ultrasound
Good for pediatric neck masses, thyroid masses. Differentiates cystic versus solid.
Computed tomography
Workhorse imaging modality for adult neck masses. Provides three-dimensional relationships,
excellent detail of mucosal disease and involvement of adjacent bone.
Magnetic resonance imaging
Superior soft tissue delineation. Good for lesions of the salivary glands and tongue (where dental
amalgam may obscure the view on a CT). Modality of choice for determining nerve enhancement.
Consider for thyroid imaging in cases necessitating radioiodine.
Radionuclide scanning
Useful for midline lesions in children—differentiates functioning from nonfunctioning tissue.
Positron emission tomography
Useful for staging of head and neck malignancies. Can be used in cases of unknown primary
malignant neck masses or treated neck disease.
Angiography/magnetic resonance angiography/computed
tomography angiography
Plain radiograph
Useful for lesions encasing the carotid and vascular lesions. Conventional angiography should be
considered for preoperative assessment in cases of potential carotid artery sacrifice or where
embolization is required.
Generally should not be considered in the workup of a neck mass.
Initial w/u of the unknown neck mass
• FNA  if unsuccessful or less informative 
consider Re-FNA  failure again  consider
core needle Bx  Failure again  excisional Bx
and if it was SCC, consider simultaneous neck
dissection procedure
Differentials for Unknown neck mass
Inflammatory causes
• The most common neck masses
• LAP:
– typically subside without tx
– sometimes it become necrotic and an abscess forms
(Staph./Strep.)
• Granulomatous disease: TB, atypical mycobac.,
actinomycosis, cat scratch, syphilis.
– FNA better than excision (because of the risk of nonhealing wound)
• Sialadenitis and Sialolithiasis
– Abx
– Hydration
– Warm compresses
– Massage
– sialogogues
Congenital neck masses
• TGDC
– In pediatric they are second in frequency only to LAP
– Elevates in the neck with tongue protrusion
– If it becomes infected: Avoid I&D  Choice is
Aspiration and Abx.
– Main procedure is Sistrunk procedure
• Branchial cleft anomalies
– Anomalies: cyst, sinus, fistula
– 30% of the pediatric neck masses
– 95% of them 2nd Arch anomaly:
• Manifest as a lateral neck swelling associated with an URI
• Like TGDC, avoid I&D
• Tract pathway is lateral to the ICA, and enters to the
pharynx at the tonsillar fossa
• Its swelling bulk or draining tract is anterior to the SCM
muscle
• 1st Branchial Cleft anomaly
– 1% of branchial cleft anomalies
– Associated with VII nerve
– Fistula, cyst & sinuses located between EAC and the
angle of the mandible
• Type 1: EAC duplication, contain ectodermal elements, it’s
lateral to the VII nerve
• Type 2: Contain ectodermal and mesodermal elements
(mesocartilage), it’s deep to the VII nerve
• 3rd and 4th BCA
– Extremly uncommon
– Swelling or sinus tract in the lower neck, anterior to
the SCM muscle
– 3rd: Deep to the CA, pierce thyrohyoid membrane and
enters the pharynx at pyriform sinus
– 4th: Deep to the CA, close to the thyroid gland, enters
pyriform sinus or cervical esophagus
• Dermoid
cyst:
contains
ectodermal
and
endodermal elements
• Teratomas:
– all three germ layers
– Less than 2% of all body teratomas are in H&N, most
commonly: neck and nasopharynx
• Lymphangioma  most common in posterior
triangle
• Hemangioma:
– Commonly occure in H&N and it’s present at birth
– Phases:
• Rapid expansion (6-12mo)
• Stable phase; no/minimal change occures
• Involution; usually begins by 24mo
– 50% complete in 5yr age
– Nearly all tumors regress by 10-12yr s age
Neck Neoplasms
Primary neoplasm of the neck
• Lymphoma:
– Most common H&N malignancy in Ped.
– 2nd most common overall H&N malignancy second
only to SCC (SCC is the most common H&N
cancer)
– Non Hodgkin (*5) > Hodgkin
– 90% B cell
• Thyroid neoplasm:
– Most common neoplastic anterior neck masses in all
age groups
– More than 90% of all thyroid nodules are benign
• Malignancy probability is greater in very young children,
very old age population and males
• Salivary gland neoplasm
– 1% of all H&N masses
– MEC is the most common salivary malignancy
• Salivary gland neoplasm, Continue:
• %80 is from parotid gland  %80 benign  majority: benign
mixed tumor
• %15 SMG  %50 malignant
• %5 S.Lingual & minor glands  More than %75 malignant
– Neurogenic Neoplasm:
• Schwanoma
– Is the most common neurogenic tumor
– Parapharyngeal space is a common location
• Neurofibroma
– There is a %2-6 risk of malignant degeneration (malignant nerve sheet
tumor)
• Neurogenic Neoplasm, Continue:
– Neuroblastoma, ganglioneuroblastoma, . . .
– Neuroma  it is a complication of truma, mainly
greater auricular nerve
• Paraganglioma  neuroectodermal origin
– Carotid body (angiographyLyre’s sign)
– Jugulotympanic region  usually not a neck mass
– Vagus nerve
• Lipoma
Work up for Unknown Primary, SCC
of the Neck
1. complete physical examination (inspection and
palpation) of all head and neck subsites
Oral cavity
Oropharynx
Thyroid
Salivary glands
Face/scalp/neck skin
2. Fiberoptic endoscopy examination
Nasal cavity
Nasopharynx
Oropharynx
Hypopharynx
Larynx
3.
Fine-needle aspiration
Table 116-2 -- Steps in the Workup of an Unknown Primary Squamous Cell
Carcinoma of the Neck
4. Primary imaging
Head and neck (computed tomography or magnetic resonance
imaging)
Chest (radiograph or computed tomography)
5. Secondary imaging
Positron emission tomography
6. Panendoscopy/ Directed
mucosal site sampling
Include laryngoscopy, bronchoscopy, esophagoscopy, and
ipsilateral tonsillectomy.
Pay close attention to the tongue base and hypopharynx.