ENT SC020: I Have A Swelling In The Neck: Neck Mass

Question 1

Classification of Neck mass

Answer 1

Benign:

• Congenital (e.g. Cystic hygroma, Branchial cyst, Thyroglossal cyst, Lymphangioma)
• Infective (e.g. LN from TB, Bacteria)
• Physiological (e.g. Prominent omohyoid muscle)

Malignant:

• Primary (e.g. Parotid tumour)
• Secondary (e.g. LN metastasis)

Question 2

Diagnosis of neck mass

Answer 2

1. Age
2. Rate of growth
3. Clinical features
   - Site
   - Size
   - Shape
   - Surface
   - Edge
   - Consistency (Rubbery LN: Lymphoma)
   - Mobility
   - Tenderness
   - Pulsation (Carotid body tumour, Aneurysm)
   - Transillumination (Cystic hygroma)

Question 3

Supraclavicular fossa mass

Answer 3

DDx:

1. Secondary deposits
   - primary malignancies in GI tract
   - small primary papillary cancer of thyroid with lower neck LN metastasis
2. Other causes of LN enlargement
   - TB LN (redness, low fever, non-tender)

Question 4

Lateral neck mass (more common than Midline mass)

Answer 4

Upper neck:
- Salivary gland pathology
—> e.g. Pleomorphic adenoma

Under the cover of SCM muscle:
- Deep cervical LN
—> Inflammatory
—> Neoplastic (Cancer of pharynx (nasopharynx, oropharynx, hypopharynx), Carcinoma of tonsil / tongue base (HPV +ve))

Other lesions:
- Thyroid tumour (SpC Revision)
- Branchial cleft cysts
- Neurofibroma
- Carotid body tumour (Pulsatile)
- Sarcoma etc.

Question 5

Midline neck mass

Answer 5

Lower neck:
- Thyroid gland lesions
(- Lipoma
- Sebaceous cyst)

Upper neck:
- Thyroglossal cyst

Question 6

Investigations of Neck mass

Answer 6

1. Fine needle aspiration cytology
   - undifferentiated SCC —> suspect NPC —> EBV DNA should be checked —> if elevated —> endoscopy +/- biopsy of nasopharynx
2. Endoscopic examination
   - ***mandatory if metastatic cervical LN suspected
   —> sites of possible primary tumour in the upper aerodigestive tract
   —> biopsy if indicated
3. Imaging studies
   - Plain X ray (not very useful)
   - CT
   - MRI
   - Angiography (for carotid body tumour)
4. PET

Question 7

Surgery in searching Primary malignancy in confirmed metastatic LN

Answer 7

1. Right tonsillectomy + Frozen section
2. Left tonsillectomy
3. Pharyngoscopy biopsy of Hypopharynx + Tongue base
4. Nasopharyngoscopy + biopsy

Question 8

Treatment of Neck mass

Answer 8

• Depends on nature of mass

Congenital lesion:

• removed surgically at appropriate age
• increase in size may lead to functional disturbances

LN:
- **investigated rather than excised —> look for **cause
- Malignant LN: ALL efforts should be spent to find **Primary tumour
- Excision LN biopsy
—> done as **last resort **after searching for primary tumour / cause
—> when **lymphoma suspected —> excised LN should be sent as fresh specimen
—> Infection LN: Treat with antibiotic
—> TB LN: Treat with Anti-TB chemotherapy

Subsequent management:

• Recurrence of pathologies (both Benign / Malignant) —> Treated
• LN treated for unknown primary —> ***Follow up regularly