Evaluation of Neck Masses in Adults JAMES HAYNES, MD; KELLY R. ARNOLD, MD; CHRISTINA AGUIRRE-OSKINS, MD; and SATHISH CHANDRA, MD, University of Tennessee Health Science Center College of Medicine, Chattanooga, Tennessee Neck masses are often seen in clinical practice, and the family physician should be able to deter- mine the etiology of a mass using organized, efficient diagnostic methods. The first goal is to determine if the mass is malignant or benign; malignancies are more common in adult smokers older than 40 years. Etiologies can be grouped according to whether the onset/duration is acute (e.g., infectious), subacute (e.g., squamous cell carcinoma), or chronic (e.g., thyroid), and fur- ther narrowed by patient demographics. If the history and physical examination do not find an obvious cause, imaging and surgical tools are helpful. Contrast-enhanced computed tomogra- phy is the initial diagnostic test of choice in adults. Computed tomography angiography is rec- ommended over magnetic resonance angiography for the evaluation of pulsatile neck masses. If imaging rules out involvement of underlying vital structures, a fine-needle aspiration biopsy can be performed, providing diagnostic information via cytology, Gram stain, and bacterial and acid-fast bacilli cultures. The sensitivity and specificity of fine-needle aspiration biopsy in detecting a malignancy range from 77% to 97% and 93% to 100%, respectively. (Am Fam Physician. 2015;91(10):698-706. Copyright © 2015 American Academy of Family Physicians.) CME This clinical content he primary concern in adults with creating a hematoma. Small hematomas conforms to AAFP criteria a persistent neck mass is malig- are typically self-limited, but large, rapidly for continuing medical education (CME). See nancy. Fortunately, a history and expanding hematomas require immediate CME Quiz Questions on physical examination coupled intervention and possible surgical explora- page 680. Twith an organized diagnostic evaluation tion. Similar mechanisms of trauma, plus Author disclosure: No rel- typically reveal a definitive diagnosis. When the addition of shearing forces, potentiate evant financial affiliations. the etiology is elusive, a head and neck sur- the formation of pseudoaneurysms or arte- geon should be consulted. riovenous fistulas characterized by soft, pul- satile masses with a thrill or bruit. Computed Anatomic Considerations tomography (CT) angiography delineates Neck anatomy is divided into triangles with the extent of any possible vascular injury, the sternocleidomastoid being the central and treatment is usually surgical ligation.1 component of each division. The anterior By far, the most common cause of cervical and posterior cervical triangles share a com- lymphadenopathy is infection or inflamma- mon border with the sternocleidomastoid. tion created by an array of odontogenic, sal- The common pattern of lymphatic drain- ivary, viral, and bacterial etiologies. These age is helpful in diagnosing metastases from lymph nodes are often swollen, tender, and various organs (Figure 1). mobile, and can be erythematous and warm. Upper respiratory symptoms caused by Differential Diagnosis common viruses usually last for one to two A clinically relevant approach to differenti- weeks, whereas lymphadenopathy gener- ating neck masses depends on whether the ally subsides within three to six weeks after mass is acute, subacute, or chronic (Tables 1 symptom resolution.2 Although unknown and 2). viruses cause 20% to 30% of upper respira- tory infections, which occur an average of ACUTE NECK MASSES two to four times per year in adults, more Neck masses that appear over a short period common viral pathogens include rhino- are generally symptomatic. Blunt or sharp viruses, coronaviruses, and influenza.3,4 trauma may damage tissue and vasculature, Biopsy is appropriate if an abnormal node 698Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2015 American Academy ofVolume Family Physicians.91, Number For 10the ◆private, May 15,noncom 2015- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Neck Masses Upper jugular chain area or jugulodigastric area (posterior auricular nodes): nasopharynx Sternocleidomastoid muscle Submandibular triangle (submandibular group): anterior two-thirds of the tongue, floor of the mouth, Posterior triangle lymph nodes: gums, mucosa of the cheek nasopharynx, posterior scalp, ear, temporal bone, or skull base Submental triangle (submental nodes): rarely involved early except from cancer of the lip Midjugular chain area (deep lateral cervical Posterior cervical triangle nodes): any portion of the oral cavity, pharynx, or larynx, especially growths in the Waldeyer ring (nasopharynx, tonsil, base of the tongue) Lower jugular chain area (supraclavicular nodes): thyroid, piriform sinuses, upper esophagus; rarely from primary below the clavicle Anterior cervical triangle ILLUSTRATION DAVE BY KLEMM Figure 1. Cervical triangle anatomy with common lymph node locations and drainage areas. has not resolved after four to six weeks, and should be performed promptly in patients Table 1. Relative Prevalence of Neck Mass Etiologies with other findings suggestive of malig- nancy, such as night sweats, fever, weight Type Common Uncommon Rare 5 loss, or a rapidly growing mass. Certain Acute Cytomegalovirus Acute sialadenitis — infectious etiologies (human immunode- infection Arteriovenous fistula ficiency virus [HIV], Epstein-Barr virus, Epstein-Barr virus Bartonella henselae cytomegalovirus, toxoplasmosis) tend to infection infection cause generalized lymphadenopathy, which Staphylococcal or Hematoma streptococcal emphasizes the need for a comprehensive Human immunodeficiency infection lymph node evaluation.1 virus infection Toxoplasmosis Bacterial infections of the head and neck Mycobacterium Viral upper tuberculosis infection predominantly cause cervical lymphade- respiratory Parotid lymphadenopathy nopathy. Lymphadenopathy caused by infection Pseudoaneurysm Staphylococcus aureus or group A beta Strep- Subacute Squamous cell Amyloidosis Castleman tococcus has no predictable sites of lymph carcinoma Lymphoma disease of the upper node inflammation. DisseminatedEpstein- Metastatic cancer Kikuchi disease aerodigestive Barr virus or HIV infection often involves Parotid tumor Kimura disease 2 tract the cervical chain. Common antibiotics Sarcoidosis Rosai-Dorfman disease used for lymphadenopathy include first- Sjögren syndrome generation cephalosporins, amoxicillin/ Chronic Thyroid Branchial cleft cyst Liposarcoma clavulanate (Augmentin), or clindamycin. pathology Carotid body tumor Parathyroid Bartonella henselae infection causes Glomus jugulare tumor carcinoma mobile, fluctuant, erythematous, and tender, Glomus vagale tumor but characteristically isolated, lymph nodes Laryngocele similar to lymphadenopathy caused by Lipoma staphylococcal and streptococcal infections. Thyroglossal duct cyst Cat-scratch disease develops when a kitten May 15, 2015 ◆ Volume 91, Number 10 www.aafp.org/afp American Family Physician 699 Neck Masses Table 2. Differential Diagnosis of Neck Masses in Adults Condition History/risk factors Physical findings Diagnosis Management Acute Acute sialadenitis Older, debilitated persons with dehydration Rapid or gradual onset of pain and swelling; local Contrast-enhanced CT Sialagogues, gentle massage; or recent dental procedures edema, erythema, tenderness, or fluctuance abscess, express by compressing consistent with an abscess the gland Hematoma Trauma Soft, possible overlying ecchymosis Ultrasonography or contrast-enhanced CT Monitor if small; surgical drainage if large or expanding Pseudoaneurysm or arteriovenous Trauma with shearing forces Lateral; soft, pulsatile mass with a thrill or bruit CT with or without CT angiography Surgical evaluation for ligation fistula Reactive lymphadenopathy Bartonella henselae infection Kitten or flea exposure Isolated, mobile, fluctuant, tender, warm, Bartonella antibody titers Azithromycin (Zithromax) erythematous, > 2 cm near site of inoculation Cytomegalovirus URI symptoms Rubbery, mobile, cervical, and generalized; > 2 cm Cytomegalovirus titer Biopsy if no resolution after 8 weeks Epstein-Barr virus infection URI symptoms Rubbery, mobile, cervical, and generalized; > 2 cm Monospot, Epstein-Barr virus titer Biopsy if no resolution after 8 weeks HIV infection Blood/sexual contact Rubbery, mobile, cervical, and generalized HIV enzyme-linked immunoassay Highly active antiretroviral therapy Mycobacterium tuberculosis Travel to or immigration from an endemic Diffuse, bilateral lymph nodes (multiple, fixed, firm, Purified protein derivative test to rule out Antibiotics: rifampin and isoniazid; (extrapulmonary) area, homelessness, immunocompromise nontender) atypical mycobacteria infection; acid- add pyrazinamide and ethambutol fast bacilli culture or streptomycin in endemic areas; refer to a head and neck surgeon if persistent after initial diagnosis and treatment Staphylococcal or streptococcal Skin infections Mobile, fluctuant, tender, warm, erythematous Clinical Antibiotics infection Toxoplasmosis Cat feces exposure Rubbery, mobile, cervical, and generalized Toxoplasmosis antibody titer Supportive care or treat with pyrimethamine and sulfadiazine Viral URI URI symptoms Mobile, rubbery, bilateral; subsides in 3 to 6 weeks Clinical Biopsy if no