I I David T. Johnson Diagnosis of a Mass in the Neck SUMMARY SOMMAIRE A mass in the neck can occur because of L'apparition d'une masse cervicale peut etre due a des facteurs de croissance, a une maladie des developmental factors, lymphadenopathy, glandes salivaires, a une lympho-adenopathie ou a salivary gland disease, or neuromas. It is des neurinomes. Pour evaleur ces masses, il est important to examine areas other than the important d'examiner d'autres regions que le cou. neck in assessing these masses, most of Un bon questionnaire, un bon examen medical et de which can be diagnosed by a good simples tests de laboratoire decrits dans I'article history/physical examination and simple permettent de poser un diagnostic dans la plupart laboratory tests, described here. (Can Fam des cas. Physician 1981; 27:1393-1396). I Dr. Johnson is an vary gland ducts for the presence of Neck masses may be divided into otolaryngologist on active staff at pus or calculi. The motility of the medial and lateral groups. Those in the the Dr. Everett Chalmers Hospital, tongue is assessed; reduction may be medial are related mainly to the Fredericton. Reprint requests to: due to tethering by tumor. Unilateral thyroid gland or thyroglossal duct and Dr. Everett Chalmers Hospital, tonsillar swelling may be a lymphoma are discussed later. Rue Priestman, P.O. Box 9000, or may have resulted from medial dis- Table 1 shows a simple scheme Fredericton, NB. E3B 5N5. placement by a parapharyngeal space which includes most of the lateral neck HE PATIENT with a neck mass mass, such as a tumor of the deep lobe masses. I presents an interesting exercise in of the parotid. diagnosis. In some, the history and ap- Palpation, including bimanual, can Developmental Causes pearance are pathognomonic; others be very useful. The consistency of the A cystic hygroma is a mass of mul- will require extensive investigation. mass can be felt and salivary calculi or tilocular, communicating cysts con- Yet others are not identified until re- tumors may be found in areas not visi- taining clear or straw colored fluid. moved and examined microscopically, ble, such as the posterior third of the Arising as an error in the development which should be the final diagnostic tongue. Mirror examination of that of lymph channels, it is usually appar- step, since premature biopsy may ad- area as well as the larynx, hypo- ent at birth or within the first few years versely affect the patient. Enucleation pharynx and postnasal space is not a of life. It is most commonly found in of a salivary tumor or biopsy of a difficult technique to master. the posterior triangle or root of the metastatically involved lymph gland, Cranial nerve palsies or Homer's neck and occasionally can be found for example, may diminish the chance syndrome may be a result of extension elsewhere in the body such as axilla or of cure' and biopsy of a carotid body of postnasal space tumor or serious groin. Sometimes a large hygroma tumor will produce hemorrhage, neck space infection. may extend well into the face and sometimes massive. On examining a patient complaining mediastinum. The history and physical examina- of a lump in the neck, one should first Similar in consistency to lipoma, it tion will always include the rest of the exclude normal anatomy. Patients may has a less defined edge and is partially head and neck, and often other areas believe the following to be tumors: the compressible due to the communica- such as breast, axillae, chest and abdo- transverse process of the first cervical tion between cysts. The most charac- men. Symptoms such as nasal obstruc- vertebra, found just below and anterior teristic feature is its ability to transillu- tion, epistaxis, rhinorrhea, change in to the mastoid tip, the greater cornua minate brilliantly. Occasionally a very fit of dentures, dysphagia or hoarse- of the hyoid bone or a prolapsed sub- large hygroma may jeopardize respira- ness may lead towards the diagnosis. mandibular salivary gland in an older tion or produce feeding difficulties; The mouth is examined without den- patient. tracheostomy and early surgery may tures with a good light, preferably a Sebaceous cysts and lipomas are be indicated. There is a significant head light or mirror which leaves both found in this area as elsewhere, but mortality rate in these patients. Aspira- hands free. Areas to be remembered beware of the 'sebaceous cyst' near the tion of some cystic fluid may be help- include the floor of the mouth between angle of the jaw or pinna which may ful in an acute problem. the tongue and the posterior part of the be a first branchial cleft cyst, with The majority of patients are seen for mandible, where small tumors can close relationship to the facial nerve, the cosmetic problem and here the hide, and the papillae of the major sali- or a tumor in the tail of the parotid. treatment may simply be observation CAN. FAM. PHYSICIAN Vol. 27: SEPTEMBER 1981 1393 until the teens or surgical excision. dehiscence in the inferior constrictor ulopapular rash. The blood picture is Complete removal is not always easy muscle of the pharynx. Both are ac- also lymphocytosis with atypical lym- due to the cysts' infiltration of sur- quired as a result of increased intralu- phocytes and a negative heterophil an- rounding tissues, which makes 'shell- minal pressure. Laryngoceles are air- tibody test. Diagnosis is made by ing out' difficult. Figure 1 shows a containing sacs arising as herniations serology and lymph node culture or cystic hygroma in a four-year-old girl. through the laryngeal ventricles. They histology. This was first noticed at age two, al- lie on the external aspect of the larynx The most important of the differen- though the mother says this side was and can be compressed, often with a tial diagnoses of infectious mononu- always more chubby. hiss of air escaping. They are seen in cleosis is of course acute leukemia. A cavernous hemangioma will have wind instrument players, glass blowers The rapidly increasing anemia, evi- a similar history and appearance to a and patients with a chronic cough. dence of coagulation problems with cystic hygroma but it will not transillu- X-ray with Valsalva's maneuver will epistaxis, bleeding gums and petechia minate. It will often be associated with demonstrate air in the sac. Treatment and the typical blood and bone marrow other hemangioma of the skin or will is excision. smears make this diagnosis. have a bluish appearance through the By the time the patient with a Tuberculosis used to be a common skin. Hemangiomata are the common- Zenker's diverticulum has developed cause of chronic cervical lymph node est parotid 'tumors' in children. They the compressible cystic swelling in the enlargement and may still occasionally tend to regress with time. lower, usually left, lateral neck, other be seen. The glands can be matted to- Although branchial cysts have a symptoms will be well in evidence. He gether and a chronic discharging sinus congenital origin from remnants of the will complain of dysphagia with regur- may follow caseation. The differential branchial clefts, they frequently do not gitation of old, undigested food, chok- diagnosis would include Hodgkin's appear until the teens or later. Those ing spells, hoarseness and weight loss. disease and chronic lymphocytic leu- arising from the second cleft, which Barium swallow is diagnostic. Treat- kemia. The latter diagnosis is made by form the vast majority, often first pres- ment is surgical and always includes examining the blood and bone mar- ent after an upper respiratory tract in- division of the cricopharyngeus mus- row. fection as a smooth, non-compressible cle, spasm of which may have been a Hodgkin's disease begins in one cystic swelling which does not transil- major cause of the herniation. group of nodes which will be discrete, luminate. They are found in the upper rubbery, non-tender and of various third of the neck just under or anterior sizes. Later, other groups are involved to the sternomastoid muscle. There Lymphadenopathy and hepatosplenomegaly occurs. may be an associated sinus opening Acute cervical adenitis may result Fever, including Pel-Ebstein, may anywhere along the anterior border of from infection anywhere within the occur as may pruritus, excessive the sternomastoid muscle below the drainage area of the upper aerodiges- sweating and also bone pain after alco- level of the hyoid. The cyst is painless tive tract and related structures, or the hol. Anemia may occur but the blood except if infected, when antibiotics are skin of the head and neck. Sometimes picture is not helpful in the diagnosis, required. If suppuration is thought to the initial site of infection may not which is made by node biopsy. have occurred, the cyst must be have been noticed or has healed, but Occasionally acute infections may drained, although this will make sub- usually it will be apparent as, for ex- spread beyond the confines of the node sequent removal more difficult. ample, a dental infection or tonsillitis. to infect the neck space containing it. The 17-year-old in Figure 2 first no- Infectious mononucleosis is usually A neck space abscess, which can be a ticed the cystic swelling two years ago associated with a sore throat and often when she started to play the bugle. My exudative tonsillitis. Lymph node en- TABLE 1 first thought was of laryngocele but the largement in other areas, as well as the Simple Subdivision of rest of the history and physical pointed neck, with possibly hepatosplenome- Lateral Neck Masses to a branchial cyst.