Condition
Comments
K – congenital
Thyroglossal duct cyst
Midline mass, moves with tongue protrusion; may become infected; most common congenital neck anomaly
Branchial cleft cyst
Lateral to midline; at risk for infection
Dermoid cyst
Arises from entrapment of epithelium during fetal midline closure
Laryngocele
Intermittent lateral neck swelling caused by herniation of a laryngeal diverticulum through the thyrohyoid membrane; may arise from chronic severe cough or sustained blowing into a musical instrument
Sebaceous cyst
Arises from obstruction of sebaceous gland duct; may become infected
Lymphangioma
Lymphatic ducts that do not communicate with the internal jugular lymphatic system resulting in impaired drainage; also known as cystic hygroma
Thymic cyst
Only requires excision if causing compression of other structures; may occasionally be ectopic parathyroid tissue
I – infectious/inflammatory
Lymphadenitis
Viral, bacterial, or fungal infection causing lymph node enlargement
Tuberculosis
Lymph nodes may be matted together and form draining sinus tract; also known as scrofula
Toxoplasmosis
May cause lymphadenitis
Cat scratch disease
May cause lymphadenitis
Actinomycosis
Suppurative lymph nodes form sinuses with a bright-red color; pus contains sulfur granules
Deep neck abscess
Present with fever, pain, stiffness, odynophagia, purulent oral secretions; retropharyngeal infection may spread to the mediastinum
T – toxin
Metals/drugs
Exposure to industrial fumes, nickel, cigarette smoke, and wood dust has been associated with head and neck cancers, which can metastasize to lymph nodes and present as a neck mass
T – trauma
Hematoma
Contusion or vascular injury; may compromise airway, may require surgical exploration
Foreign body
For example, shrapnel, bullet
Aneurysm
Blunt or penetrating injury may cause pseudoaneurysm of the carotid artery
E – endocrine
Thyroid hyperplasia
Graves’ disease, goiter
Ectopic thyroid gland
May be found anywhere along the thyroglossal duct; beware of lateral ectopic thyroid tissue as this may be metastatic spread of malignancy
N – neoplastic
Benign growths
Lipoma, neuroma, fibroma
Malignant growths
Thyroid carcinoma, lymphoma, salivary gland carcinoma, carotid body (paraganglioma)
Metastatic
Unknown primary, mucoepidermoid, adenoid cystic, lung, breast, kidney, GI
S – systemic
AIDS
Increased susceptibility to infections
Kawasaki disease
Autoimmune disease associated with coronary artery abnormalities
What Is the Most Likely Diagnosis for This Patient?
A neck mass in a patient over the age of 40 should be considered malignant until proven otherwise. The “rule of 80s” should be applied. A neck mass in an adult has an 80 % chance of being neoplastic and 80 % chance of being malignant. In contrast, 90 % of pediatric neck masses are benign. History of alcohol and tobacco use also increases the risk of cancer. The progressive increase in size of the mass is also consistent with malignancy. The absence of “B” symptoms (fever, chills, weight loss) and the unilateral nature of the mass argue against lymphoma. Furthermore, there is no history of exposure to infection (TB, cat scratch, recent travel) which would suggest an infectious etiology. In addition, infectious neck masses are typically tender, with overlying erythema. The most likely diagnosis is a metastatic lymph node (most likely squamous cell) from an unknown primary. Further work-up is needed to confirm that the neck mass is a metastatic lymph node and, if so, to find the source of the primary tumor.
What Risk Factors are Associated with Head and Neck Cancer in General?
Alcohol and tobaccoa |
|---|
Male |
Age > 40 |
Poor dental hygiene |
Radiation exposure |
African American |
What Risk Factors are Associated with Specific Head and Neck Cancers?
Risk factor | Type of cancer |
|---|---|
Human papillomavirus (HPV) | Oropharyngeal cancer |
Epstein-Barr virus (EBV) | Nasopharyngeal cancer, Burkitt’s lymphoma |
Chinese | Nasopharyngeal cancer |
GERD | Laryngeal cancer |
Plummer-Vinson syndromea | Pharyngeal and upper esophageal cancer |
What Premalignant Lesions Should be Looked for on Physical Examination?
Comments | |
|---|---|
Leukoplakia (white patch or plaque) | Buccal mucosa, alveolar mucosa, and lower lip |
Erythroplakia (red patch or lesion) | Floor of the mouth, tongue, and soft palate |
What Symptoms can be Associated with Head and Neck cancer and What are the Likely Sources?
Symptom | Definition | Pathophysiology/possible malignant sources |
|---|---|---|
Otalgia | Pain in the ear | Cranial nerves IX and X supply sensory innervation to both the tongue and floor of mouth and also supply sensory innervation to the ear. Pain can be referred to the ear from CN IX via Jacobson’s nerve and CN X via Arnold’s nerve. In addition, the lingual nerve (V3) supplies sensation to the tongue and floor of mouth as well as the external auditory canal and tympanic membrane via the auriculotemporal nerve |
Dysphagia | Difficulty in swallowing | Mass effect of tumor obstructing the path of food bolus (hypopharynx) vs. interference with swallowing mechanism (common in pharynx/tongue/hypopharynx) |
Odynophagia | Pain in swallowing | Tumor-related inflammation can cause pain |
Dysphonia | Impairment in producing voice sounds | Lesion on vocal cords blocking efficient phonation or vocal cord paralysis from neural involvement |
Dyspnea | Difficulty in breathing | Upper airway obstruction |
Trismus | Limited opening of the jaw | Tumor invasion into pterygoid muscles |
Stridor | High-pitched sound resulting from a narrowed or obstructed airway | Upper airway obstruction |
Hemoptysis | Expectoration of blood-stained sputum | Ulceration of tumor into blood vessel in upper airway vs. secondary pulmonary lesion |
What Are the Key Aspects of the Head and Neck Exam in the Evaluation of a Solitary Neck Mass?
Though it is tempting to focus completely on examination of the neck, it is imperative that a full head and neck exam be performed. This should include careful inspection and palpation of the scalp, skin, parotid, ears, ear canals, nose, nasal cavity, oral cavity, and oropharynx. In particular, the base of the tongue and tonsillar fossa should be palpated for any evidence of firmness. Full characterization of the neck mass should be performed, with assessment of the size, location, mobility, consistency, fluctuance, overlying skin changes, and associated pain. A full cranial nerve exam should be performed to assess for deficits, which are often associated with advanced head and neck cancer.
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