Evaluation of the Neck Mass
Michael Hong, MD
University of Florida
Department of Surgery
Neck Mass - History
• Age
• Rate of growth: Days / Months / Years
– Days – think infectious
– Months – think cancer
– Years – think congenital
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Fever / cough / sore throat
Recent travel, bites, animal exposure
Weight loss / night sweats
Fatigue / cold intolerance, wt gain
Nervousness, sweating, heat intolerance, exopthalmos, palpitations
Smoking / alcohol use / hx radiation
Trauma
Family history
Physical Exam
• Location of neck mass
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Lateral neck, central neck, supraclavicular, cervical
Size
Soft / Hard
Mobile / fixed
Painful / Painless
Lymphadenopathy
Differential Diagnosis
• Congenital
– Lateral neck
• Branchial cyst, sinus, fistula near SCM
– Slow, soft, painless
– Workup: FNA + biopsy
– Tx: Excision
– Medial neck
• Thyroglossal duct cyst
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thyroid gland usually travels from the base of the tongue to the neck.
Moves when swallowing
Workup: TFT, thyroid scan
Tx: Excision + removal of central hyoid bone (Sistrunk procedure)
– Ectopic thymus, parathyroid, thyroid
– Mandible – pharyngeal cyst
– Congenital torticollis – soft tissue swelling
• birth trauma, intrauterine positioning
Differential Diagnosis
• Infectious
– Abscess – staph / strep / polymicrobial
• Tx: abx +/- drainage
– TB – single large node, usu. painless, cervical
• Workup: PPD, rule out HIV
• Tx: Anti-TB meds
– Cat scratch fever – Bartonella henselae
• Single enlarged node
• Weeks to months after exposure
• Self limited
– Mono – get EBV titer
• p/w cervical adenopathy
Hyperthyroid / hypothyroid
• Goiter – enlargement of thyroid gland
– Iodine deficiency, Grave’s disease, Toxic
Multinodular Goiter, acute/subacute/chronic
thyroiditis
Tumors
• Benign
– Tx: surgical excision
– Examples:
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Lipoma
Hemangioma
Neuroma
Fibroma
Carotid body tumor
Tumors
• Malignant
– Primary
• Thyroid cancer
• Salivary gland cancer (near ear or angle of mandible)
• Lymphoma (lateral neck, rubbery and mobile)
• Sarcoma
– Secondary
• metastates
Location of metastases
• Supraclavicular – check for chest malignancy
– Virchow’s node – left supraclavicular area
Thyroid masses
• Benign thyroid nodule – palpable
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Follicular adenoma
Colloid nodule
Benign cyst
Solitary toxic adenoma (dec TSH, inc T3 & T4)
• Tx: radioactive iodine or unilateral lobectomy
Thyroid cancer
• Thyroid cancer
– Papillary – young, prior radiation, good prognosis
• Good 131 I uptake
• Lobectomy and isthectomy
• Total Thyroidectomy if diffuse/bilateral disease
– Follicular adenoma – cannot dx w/FNA
• Good 131 I uptake
• Mets to bone
• Males 3:1
• Lobectomy and isthectomy
• Total Thyroidectomy if large/diffuse
Thyroid cancer cont.
• Thyroid cancer
– Medullary Carcinoma
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Associated with MEN II
Secretes calcitonin
Poor 131 I uptake
Poor prognosis
Tx: total thyroidectomy and median lymph node dissection.
– modified neck dissection if lateral cervical nodes are positive.
– Hurthle cell – cannot dx with FNA
• Adenoma - Lobectomy and Isthmectomy
• Carcinoma - Total Thyroidectomy and modified radical neck
dissection if lat nodes are positive.
Thyroid cancer cont
• Thyroid cancer
– Anaplastic
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Poor 131I uptake
Giant cells / spindle cells on histology
Bad prognosis
Total thyroidectomy if resectable (usu. Not)
Parathyroid
• Primary hyperthyroidism
– Adenoma (85%)
• MEN I, MEN IIa
• High PTH, high Ca
• Tx: excision, confirm with intraoperative PTH
– Hyperplasia
• MEN I, MEN IIa
• Tx: remove all but one parathyroid, intraoperative PTH
– Carcinoma
• Palpable mass
• High PTH, high Ca
• Tx: resection of gland, ipsilateral thyroid lobectomy, and ipsilateral
lymph node resection.
General Workup Approach
• Rule out infectious
– EBV, heterophil titer (mono), HIV, PPD
– Abx trial
• Check thyroid / parathyroid
– TSH/T3/T4, PTH/Ca, calcitonin
• Fine needle aspiration
• Imaging
– Ultrasound: cystic vs. solid
– Radionucleotide thyroid scan
• Cold – 25% malignant
• Hot – 5% malignant
– CXR, CT (look for primary), MRI (upper neck, skull base)
Fine Needle Aspiration
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Fine needle – 25 gauge
Multiple aspirations
Used with US
5% false negative rate
Cannot distinguish benign/malignant follicular
thyroid tumors or Hurthle cell tumors
• Good for cystics vs inflammatory, papillary,
medullary, anaplastic cancers
Endoscopy
• direct laryngoscopy, esophagogastroscopy or
bronchoschopy
– FNAB positive with no primary on repeat exam
– FNAB equivocal/negative in high risk patient
• Biopsy on obvious abnormality
• Guided biopsy based on lymphatic drainage