Differential Diagnosis

of Neck Masses
The differential diagnosis of neck masses requires a systematic approach.
In children, a neck mass is
most commonly a
hyperplastic lymph node.
Congenital conditions
include thyroglossal duct
cyst, branchial cleft cyst,
cystic hygroma,
hemangioma or desmoid.
Thyroglossal duct cyst
must be differentiated
from ectopic thyroid gland
before excision.
Malignancy such as
lymphoma, soft tissue
tumors and thyroid cancer
are rare.
The Memorial Sloan Kettering
classification of lymph node
levels in the neck is shown.
Level I includes submental
and submandibular nodes.
Level II is upper deep jugular
and jugulodigastric nodes.
Level III includes mid-jugular
and jugulo-omohyoid. Level
IV are lower deep jugular and
deep supraclavicular nodes.
Level V is the posterior
triangle.
Inflammatory conditions
such as the ones listed can
cause regional
lymphadenopathy.
However, in an adult, Hayes
Martin's dictum is good to
keep in mind: An
asymptomatic solitary
lateral neck mass in an
adult is metastatic disease
until proven otherwise.
Benign non-inflammatory neck masses include glandular (see ,
vascular, neurogenic , skin and subcutaneous abnormalities or
growths.
The rule of 80s for solitary adult neck masses excluding thyroid is
that 80% of them are malignant, and 80% of malignancies are
metastatic. 80% of these come from a primary above the clavicle
and 80% of them are squamous carcinoma.
While the majority of malignant adult neck masses are
metastatic squamous pathology, other sources of metastatic
disease and primary malignancy must be considered in the
differential diagnosis and workup.
Metastatic disease follows a predictable pattern of spread, and the
location of the mass gives clues to the primary. Lymph node
metastases are firm feeling compared to soft lymphomatous
nodes.
Workup starts with a careful history including risk factors such as
smoking and alcohol use. Physical exam provides clues by location and
feel (pulsation, firmness). Panendoscopy including assessment of vocal
cord mobility is a necessity. The mainstay of diagnosis is fine needle
aspiration (FNA) which is highly reliable in experienced hands. If FNA is
non-diagnostic, excisional biopsy (or incisional if large) with preparation
for neck dissection is the next step . The bottom line is that surgical
treatment for most head and neck cancers is highly effective and initial
treatment should be aggressive.