Medicine

Establishing the differential diagnosis of neck lesions

James A. Giglio, DDS, MEdVDaniel M. Laskin. DDS. MS^

A thorough physicai examinafion of the head and neck shouid be included as part of the evaluafion of every denfai pafienf. Aithough fhey most often represent a seif-iimited infiammation, a benign neopiasm, or a congenitai anomaly, neck lesions can aiso be malignant. Because the pathoiogic iesions thaf can arise in the neck are varied and diverse, the diagnostic thought process should be orderiy and inclusive so fhal a reasonable differential diagnosis can be established and prompt, effecfive treatment can be rendered. (Ouintessence Int 2000:31:637-641)

Key words: oiassificafion, differentiai diagnosis, neck lesion, physical examination, tumor

natomically, the neck constitutes only a small per- neck masses. All classifications, however varied, are Acentage of the total body area, but it contains useful in that they help the clinician to order the diag- many vital anatomic structures and diverse tissue nostic thought process and form an initial impression types. Consequently, the pathologic lesions tbat can of the clinical findings. arise in tbe region are equally as varied and diverse. Clinical evaluation must always begin with a tho- An examination of tbe neck for lesions sbould be rough history and attention to symptoms. Most diag- included in the evaluation of every dental patient. nostic errors occur because the history and physical Various classifications of neck lesions bave been examination are inadequate and there is an overre- proposed. Some are based on anatomic location, ie, liance on sophisticated imaging techniques.* Patients median or paramedian swellings of the neck, while at risk for serious clinical problems can often be iden- others are based on tissue of origin. Sarnat and Sbour' tified through tbe findings on history taking, sucb as differentiated between primary and secondary progressive enlargement of the mass or prolonged swellings, while Sedgwick^ divided the swellings into hoarseness." A careful history will also begin to nar- tnidline, lateral, and low-lying lesions. Another classi- row tbe range of possible lesions and guide deductive fication used the organ systems approach (vascular. reasoning. For example, age can be a factor. In adults nervous, etc).^ Park-i grouped neek lesions according older tban 40 years, metastatic neoplasms are strong to their etiologic origin as inftammatory, neoplastic, or possibilities and should be considered. For example, a nontbj,Toid neck mass in an older patient has an SO^/o congenital. Burton and Pransky' included palpable probability of being neoplastic, and SO^/o of these are normal anatomic masses, such as the transverse malignant.'" In young aduks and teenagers, inflamma- process of C2, the styloid process, the mastoid tip, the tory lesions, especially from a third molar pericoroni- greater cornu of the , and the thyroid carti- tis. are common. Infectious mononucieosis and thy- lage, in their classification. Otto and Bowes^ grouped roid malignancies should also be suspected in patients lesions by patients' age, and tMcGuirt' used an algo- in this age group. Developmental lesions, as well as rithmic approach to the diagnosis and treatment of the more common response to infection and inflammation, sbould be considered in children. The patient's report of the duration tbat a lesion 'Protessor, Department ot Oral and Maxillofacial Suigery, Medical College has been present is also helpful information. A rule of of Virginia, Virginia Commonwealtti university, Sctiool of Derilistry, thumb states that a mass present for 7 days is inflam- Richmond, Virginia. matory, a mass present for 7 montbs is neoplastic, and 'Professor and Chairman, Department oí Oral and Maxiilofacial Surgery, a mass present for 7 years is congenital' Because cer- Medical College of Virginia, Virginia Commonwealth Unwersity. School ol Dentislry, Richmond, Virginia tain lesions are found in discrete anatomic locations, a Reprint requests: Dr James A Gigiio, Professor, Department ot Oral and knowledge of those associated with specific regions in Maxillotacial Surgery. PO Box 980566, Medical Coiiege of Virginia, Virginia the neck is useful in the differential diagnosis. The fol- Commonwealtti University, School of Dentistry, Richmond. Virginia 23398- lowing discussion uses this approach. 0566. E-mail: [email protected]

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Fig 1 Thyroglossal duct cyst. Fig 2 Derrfioid cy

The presence of eetopie thyroid tissue is rare but mer- its eonsideration. This midline mass can appear at the base of the in tbe region of tbe foramen (lingual thyroid), more deeply situated infraiingually, or high in the midline of the neck. Symptoms, wben pre- sent, include dyspbagia, difficulty with speecb, and a feeling of fullness in the tbroat. Before a lesion is removed, care must be taken to estabiisb that the patient has a normally functioning thyroid gland. Removal of eetopie thyroid tissue without sueh eonfirmation can cause bypotbyroidism or a myxedematous state because it may represent tbe patient's only tbyroid tissue. Fig 3 Submental abscess. The submental lympb nodes drain tbe , anterior tongue, and the region of the mandibular incisors and anterior gingiva. Enlargement of these nodes (submen- tal lymphadenitis) reflects possible patbosis in these areas. An infeetion from a mandibular incisor can cause an absecss in the submental space (Fig 3). An abseess occupying tbis space presents as an anterior DIFFERENTIAL DIAGNOSIS OF MIDLINE LESIONS swelling, which may be accompanied by dysphagia and dyspnea. Swelling of tbe submental space along Tbe following conditions ean result in midline swelling witb bilateral swelling of tbe submandibular and sub- of the neek: lingual spaces is termed Ludwig's angina; tbis condi- tion can be life-threatening unless treated aggressively. 1. Thyroglossal duct eyst 2. Epidermoid cyst 3. Dermoid cyst DIFFERENTIAL DIAGNOSIS OF 4. Submental lymphadenitis LATERAL CERVICAL SWELLINGS 5. Submental abscess 6. Tbyroid gland tumors Lateral cervical swellings can be cither discrete or 7. Ectopic thyroid multiple and located bigb or low in the neck. Because of tbeir variability, they tend to present diflicult diag- Midline swellings of tbe neck are characteristically nostic problems. caused by conditions sucb as tbe congenital thyroglos- sal duct cyst (elevates with tongue protrusion) (Fig 1), Discrete lateral swellings the developmental epidermoid or dermoiid cyst (does not elevate with tongue protrusion) (Fig 2), and neo- High-level swellings. These lesions (Table 1) are very plastic growths from the thyroid and its isthmus. often related to the major salivary glands. The ránula is

638 VoiumG3t. Nürnberg, 2000 Giglio/Laskin

TABLE 1 High-level lateral cervical swellings

Lesion Type tumor Neopiastic Sialoadenitis inilammatory Carotid body tumor Neopiastic Branchiai cieft cyst Deveiopmental Cyslic hyg roma Neopiastic Neurofibtoma Neopiastic Fibroma Neopiastic Hemangioma Neopiastic Plunging ranuia Traumatic Enlarged nodes Neopiastic /intiammatory

Fig 4 Piunging ranuia.

Fig 5 fiefi) Oöstruotive siaioactenitis.

Fig 6 (beiow) Panoramic study reveaiing calculus deposit in glanOuiar system

a form of mucous retention phenomenon that develops Sialoadenitis should be considered if the swelling is in association with either the sublingual or sub- acute and painful (Fig 5). Bidigitai palpation will martdibular gland dticts. On occasion, the ránula her- often help to define the presence of calculi within the niates through the and is stthse- glandular or duct system. Radiographs (Fig 6) and quently referred to as a plunging ránula (Fig 4). This sialography wiil confirm the diagnosis. The forming lesion is palpable high in the neck toward the midline. calculus may not have calcified and, consequently, The pleomorphic adenoma is the most common may not be evident on the radiograph. However, the salivary gland tumor and is typically associated with contrast medium used for the sialogratn will usually the ; however, it can involve the sub- not flow past such an ohstruction and thus indicates mandibular gland. When arising from the parotid its presence. gland, the tumor will be palpable as a firm, discrete, Other discrete high-level lateral cervical swellings nonftxed mass in the region of the mandihular angle. include the carotid hody tumor, the branchial eleft Pleomorphic adenomas of the submandihular gland cyst, and the cystic hygroma. The branchial cleft cyst are located in the suhmandibular triangle. The masses (Fig 7) is developmental in origin, grows slowly, and is are usually freely mobile, discrete, and not adherent to generally found in adolescents and young adults. The the overlying skin. Malignant tumors of the sub- freely mobile, painless lesion is usually located ante- mandibular gland should be suspected if the patient is rior to the sternoelcidomastoid muscle in the upper an older adult and the swelling is firm and fixed, con- third of the neck. Aspiration will reveal cholesterol tinues to enlarge, and is painful. crystals, which are diagnostic for the lesion.

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The goiter can be palpated in the root of the neck above the clavicle. It causes deviation of the trachea and ascends and descends with swallowing. The esophageal fibroma is a rare tumor. It too ascends and descends with swallowing and cannot be differentiated clinically from a goiter. Pirm, palpable lympb nodes in fhe supraclavicular region may represent metastafic carcinoma from the . In addition, a supraclavicular mass requires evaluation for generalized adenopathies and possible infraclavicular neoplasms (eg, lung, breast, ovary, testes, colon), because masses in the lower neck commonly arise from pathosis below the clavicle,'" Fig 7 Branctiial clelt cyst. Sarcoidosis is a disease of unknown etiology char- acterized by epithelioid-cell follicuiar formations within the organs involved. The lungs and lymph nodes are frequent sites of involvement. Lympha- denopathy is most marked in the peribronchial region.'^ Consequently, enlarged lymph nodes may be palpated low in tbe neck above the lung apices.

Carotid body tumors are small, discrete masses Multiple lateral cervical swellings located beneath the angle of the at the bifur- cation of the common carotid artery. They are usually Multiple lateral neck swellings usually involve the asymptomatic and can be confused with the branchial lymphatic system. Enlarged, tender cervical lymph cleft cyst. However, carotid body tumors are located nodes are frequently observed in young children, deeper, usually are firm, and cannot be displaced verti- Odontogenic infection and tonsillitis are common cally as readily as the branchial cleft cyst. causes. Frequently, following acute infection, the The cystic hygroma (lymphangioma) is usually involved nodes will remain enlarged for extended peri- found in infants and children. It is palpable as a soft ods. For example, cer\'ical nodes enlarged because of mass posterior to the sternocleidomastoid muscle. The infection with the gram-negative bacteria thaf cause lesion is initially asymptomatic but can enlarge to pro- cat-scratch disease will remain enlarged for 2 to 4 duce symptoms of pressure in the region of the tra- months following remission of the disease. These chea. They are frequently associated with karyotypic nodes arc freely movable, occasionally tender, but not abnormalities and various malformation syndromes." unduly firm." Neurofibroma, iipoma, fibroma, and hemangicma Pulmonary tuberculosis may be disseminated by should also be included in the differential diagnosis of either lymphatic or vascular spread. Localized infec- discrete lateral cervical swellings. tion of the cervical lymph nodes is termed scrofula. The sternocleidomastoid tumor of infancy (STOI) is The infected nodes hecome swollen and palpable, and relativeiy uncommon, presenting as a firm, well-cir- these nodes are typically painful or tender. They may cumscrlbed mass within the sternocleidomastoid mus- abscess or remain as a granulomatous lesion,'^ cle in infants 1 to 8 weeks of age; the tumor may be Fixed, firm, enlarged, and painless nodes in the associated with torticollis. The STOI must be consid- neck may be indicative of lymphatic spread of a pri- ered in any infant with a lateral neck mass. It usually mary carcinoma in the oral cavity, oronasal , is a unilateral condition, but bilateral involvement maxillary sinus, nasal cavity, or facial region. A neck does occur.'^ swelling may be the first clinical manifestation oí such Low-level swellings. Tbe following conditions can cancers. These masses are typically located behind and result in low-level lateral cervical swelling: below fhe mandibular gonial angle. A thorough oral, nasal, and pharyngeal examinafion should be per- 1. Infrafhoracic goiter formed to rule out a primary lesion. Enlarged, matted 2, Esophageal fibroma cervical nodes can also be indicative of a primary dis- 3, Metastatic carcinoma ease such as lymphoma, leukemia, Hodgkin's disease, 4. Sarcoidosis or tuberculosis.

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DISCUSSION 4. Park YW. Evaluation of neck masses in children. Am Fam Physl995;5!:1904-1912. This article describes a simple method of distinguishing 5. Burton DM, Pransky SM. Practical aspects of managing cervical masses hased on their particular location in non-malignant lumps in the neck. J Otoiaryngol 1992;21: 398-403. the neck. Such swellings should always he viewed with 6. Otto RA, Bowes AK. Nt;c:k masses: Benign or malignant? a high index of suspicion. Because of the possibility of Sorting out the causes by age group. Postgrad Med 1990; primary tumors arising in the neck and the frequent 88(l);199-204. occurrence of metastatic lymph nodes, many clinicians 7. McGuirt WF. Diagnosis and management of masses in the consider all neck lesions as malignant until proven neck, with special emphasis on metastatic malignant dis- otherwise. This approach, while sound, should be used ease. Oncology (Huntingt] 1990 ;4(S):85-92,97 tactfully so as not to cause undue alarm in the patient. 8. Bunipous |M, Fiynn MB Practical steps in the management Careful evaluation of data assembled from the his- of aduit head and neck masses. J Ky Med Assoc 1996;94(2): 50-56. tory, physical examination, plain radiographs, com- 9. Armstrong WB, Giglio MF. Is this lump in the neck any- puted tomography, and magnetic resonance imaging thing to worry about? Postgrad Med 1998;104(3). will help to establish a preliminary clinical diagnosis. 63-64 Fine-needle aspiration and/or surgical biopsy will 10 Reibel JP. The patient with a neck mass. Compr Ther 1997; establish the definitive diagnosis and dictate the final 23:737-741. course of treatment. 11. Gallagher PG, Mahony MJ, Gosch |R. Cystic hygroma in the fetus and newborn. Semin Perinatol 1999;23:341-356. 12. Tufano RP, Tom LW, Austin MB Bilateral sternocleidomas- toid tumors of infancy. lnl ] Pediatr Otorhinolaryngol REFERENCES 1999;5111):41-45 13. Robbins SL, Angelí M. Basic Pathology, ed 2. Philadelphia: 1. Sarnat BG, Shour I. Controi of Oral and Facial Cancer. Saunders, 1976:421. Chicago; Year Book, 1950:226-231. 14. August JR. Cat scratch disease. J Am Vet Med Assoc 2. Sedgwicit CE Tumors of the neck. Surg Clin North Am 1988:193:312-315. 15. Shafer WG. Hine MK, Levy BM A Textbook of Oral 5. Bawer T. Teaching rounds: Differential diagnosis of neck Pathology, cd 4. Philadeipiiia: Saunders, 1983.310-312. masses. Hosp Med 1986:22 66-75. HARVARD survives the test of time

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