Symptom Finder - Neck Mass
NECK MASS
Anatomy is the most important basic science used in developing the differential diagnosis in the case of a neck mass. Histology is then applied to each anatomic structure to further develop the list. As with any mass, a neck mass may be due to the proliferation of tissues in any of the anatomic structures, a displacement or malposition of tissues or anatomic structures, or the presence of fluid, air, bleeding, or other substances foreign to the neck.
Visualize the anatomy of the neck and think of the skin, thyroid, lymph nodes, trachea, esophagus, jugular veins, carotid arteries, brachial plexus, cervical spine, and muscles. Thus, taking thyroid enlargement, hypertrophy and cystic formation (endemic goiter), hyperplasia (Gravesdisease), neoplasm (adenomas and carcinomas), thyroiditis (subacute or Hashimoto), cyst (colloid type), and hemorrhage come to mind. Thyroglossal duct cysts also occur.
Lymph nodes may be enlarged by many inflammatory diseases, but when they present as an isolated mass they are usually infiltrated with Hodgkin lymphoma or a metastatic carcinoma from the thyroid, lungs, breast, or stomach. Tuberculosis, actinomycosis, and other chronic inflammatory diseases may present this way. Tracheal enlargement is rarely a problem in differential diagnosis, but bronchial cleft cysts may present as a mass. Pulsion diverticula are the main masses of esophageal origin, but carcinoma of the esophagus may involve the upper third on rare occasions. There is rarely a problem distinguishing jugular veins from a mass of other origin. Carotid or subclavian artery aneurysms are distinguished by their pulsatile nature; occasionally, an aortic aneurysm may be felt in the neck. When there is severe atherosclerotic disease of the carotids, one or both may be felt as a “lead pipe” in the neck.
Neurofibromas of the brachial plexus are rare but must be considered. Any neoplasm that metastasizes to the cervical spine may spread into the neck; a plasmacytoma is likely to do this in multiple myeloma. A cervical rib may occasionally be felt in the neck. Finally, a large scalenus anterior muscle may be felt as a mass in the neck.
Neoplasms of the skin present here, as elsewhere (e.g., lipoma). Abnormal accumulations of fluid, air, or other substances in colloid cysts and bronchial cleft cysts have already been mentioned, but what about carbuncles, sebaceous cysts, and angioneurotic edema? Cystic hygromas present from birth contain a serous or mucoid material and may be huge. Finally, subcutaneous emphysema must not be forgotten.
Approach to the Diagnosis
The clinical picture will help to determine the diagnosis in many cases. For example, a neck mass with hemoptysis suggests carcinoma of the lung with metastasis to the lymph node. A diffuse, tender, and enlarged thyroid suggests subacute thyroiditis. If the mass increases in size after swallowing food or liquid, an esophageal diverticulum is likely. A thyroglossal duct cyst moves on protruding the tongue.
The workup will depend on the type of lesion suspected. If the mass is suspected to be an enlarged lymph node, exploration and biopsy may be appropriate. An esophageal diverticulum can be ruled out by a barium swallow or esophagoscopy. A thyroid profile will show an increased T4 in subacute thyroiditis. A radioiodine uptake and scan may be indicated to diagnose other thyroid masses. A thyroid cyst may be suspected by ultrasonography or CT scan, but it is confirmed by fine needle aspiration. If the mass is connected to the cervical spine, a CT scan or magnetic resonance imaging (MRI) of the cervical spine should be ordered. One can now see that the diagnostic workup can be developed by visualizing the anatomy of the area.
Other Useful Tests
1. CBC
2. Sedimentation rate (inflammation)
3. Chest x-ray (neoplasm, tuberculosis, fungal disease)
4. X-ray of cervical spine (neoplasm)
5. Tuberculin test (tuberculosis)
6. Serum protein electrophoresis (multiple myeloma)
7. Bone scan (osteomyelitis, neoplasm)
8. Bronchoscopy (neoplasm of the lung)
9. CT scan of the mediastinum (neoplasm, superior vena cava
syndrome)
10. CT scan of the neck (thyroid malignancies)
11. MRA or 4-vessel cerebral angiography (aneurysm)
Anatomy is the most important basic science used in developing the differential diagnosis in the case of a neck mass. Histology is then applied to each anatomic structure to further develop the list. As with any mass, a neck mass may be due to the proliferation of tissues in any of the anatomic structures, a displacement or malposition of tissues or anatomic structures, or the presence of fluid, air, bleeding, or other substances foreign to the neck.
Visualize the anatomy of the neck and think of the skin, thyroid, lymph nodes, trachea, esophagus, jugular veins, carotid arteries, brachial plexus, cervical spine, and muscles. Thus, taking thyroid enlargement, hypertrophy and cystic formation (endemic goiter), hyperplasia (Gravesdisease), neoplasm (adenomas and carcinomas), thyroiditis (subacute or Hashimoto), cyst (colloid type), and hemorrhage come to mind. Thyroglossal duct cysts also occur.
Lymph nodes may be enlarged by many inflammatory diseases, but when they present as an isolated mass they are usually infiltrated with Hodgkin lymphoma or a metastatic carcinoma from the thyroid, lungs, breast, or stomach. Tuberculosis, actinomycosis, and other chronic inflammatory diseases may present this way. Tracheal enlargement is rarely a problem in differential diagnosis, but bronchial cleft cysts may present as a mass. Pulsion diverticula are the main masses of esophageal origin, but carcinoma of the esophagus may involve the upper third on rare occasions. There is rarely a problem distinguishing jugular veins from a mass of other origin. Carotid or subclavian artery aneurysms are distinguished by their pulsatile nature; occasionally, an aortic aneurysm may be felt in the neck. When there is severe atherosclerotic disease of the carotids, one or both may be felt as a “lead pipe” in the neck.
Neurofibromas of the brachial plexus are rare but must be considered. Any neoplasm that metastasizes to the cervical spine may spread into the neck; a plasmacytoma is likely to do this in multiple myeloma. A cervical rib may occasionally be felt in the neck. Finally, a large scalenus anterior muscle may be felt as a mass in the neck.
Neoplasms of the skin present here, as elsewhere (e.g., lipoma). Abnormal accumulations of fluid, air, or other substances in colloid cysts and bronchial cleft cysts have already been mentioned, but what about carbuncles, sebaceous cysts, and angioneurotic edema? Cystic hygromas present from birth contain a serous or mucoid material and may be huge. Finally, subcutaneous emphysema must not be forgotten.
Approach to the Diagnosis
The clinical picture will help to determine the diagnosis in many cases. For example, a neck mass with hemoptysis suggests carcinoma of the lung with metastasis to the lymph node. A diffuse, tender, and enlarged thyroid suggests subacute thyroiditis. If the mass increases in size after swallowing food or liquid, an esophageal diverticulum is likely. A thyroglossal duct cyst moves on protruding the tongue.
The workup will depend on the type of lesion suspected. If the mass is suspected to be an enlarged lymph node, exploration and biopsy may be appropriate. An esophageal diverticulum can be ruled out by a barium swallow or esophagoscopy. A thyroid profile will show an increased T4 in subacute thyroiditis. A radioiodine uptake and scan may be indicated to diagnose other thyroid masses. A thyroid cyst may be suspected by ultrasonography or CT scan, but it is confirmed by fine needle aspiration. If the mass is connected to the cervical spine, a CT scan or magnetic resonance imaging (MRI) of the cervical spine should be ordered. One can now see that the diagnostic workup can be developed by visualizing the anatomy of the area.
Other Useful Tests
1. CBC
2. Sedimentation rate (inflammation)
3. Chest x-ray (neoplasm, tuberculosis, fungal disease)
4. X-ray of cervical spine (neoplasm)
5. Tuberculin test (tuberculosis)
6. Serum protein electrophoresis (multiple myeloma)
7. Bone scan (osteomyelitis, neoplasm)
8. Bronchoscopy (neoplasm of the lung)
9. CT scan of the mediastinum (neoplasm, superior vena cava
syndrome)
10. CT scan of the neck (thyroid malignancies)
11. MRA or 4-vessel cerebral angiography (aneurysm)
