Tune in to our seventh episode to learn a concise and comprehensive approach to a common otolaryngology presentation - adult neck masses!

Show Notes

Introduction:

Hey everyone and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things otolaryngology. I'm your host, Aileen, and today we're going to talk about an approach to adult neck masses. Tag along for a discussion about this common otolaryngology presentation, and stick around to hear some high yield tips at the end. 

A neck mass is an abnormal lump in the neck of any size, and of many different etiologies (American Academy of Otolaryngology- Head and Neck Surgery, 2021). 

Causes/Etiology: 

It’s important to realize that not all neck masses mean tumour or cancer! Other etiologies of neck masses include congenital, infectious, inflammatory, autoimmune, metabolic, idiopathic, or traumatic (Fried, 2020; Schwetscheau and Kelley, 2002). To simplify this, neck masses most commonly fit into one of three broad categories, being a congenital anomaly, an infectious or inflammatory condition, or a neoplasm (Schwetschenau and Kelley, 2002). 

Congenital masses are commonly found in children, however, they can be slow growing and persist into their adult years (Haynes et al, 2015). Therefore, congenital masses should be considered in the differential diagnosis of a neck mass, even in adults (Schwetschenau and Kelley, 2002). The most common congenital neck masses include thyroglossal duct cysts, dermoid or sebaceous cysts, and branchial ((brank-e-le) cleft cysts (Fried, 2020). Thyroglossal duct cysts are midline neck masses found adjacent to the hyoid bone (Haynes et al, 2015). They are the most common congenital cervical anomaly and result from incomplete closure of the thyroglossal duct, which is the path that the thyroid gland takes from the tongue base to the inferior neck during development (Amos and Shermetarp, 2021). Branchial ((brank-e-le) cleft cysts, representing 22% of congenital neck masses, are divided into first, second, third and fourth branchial cleft cysts. Remember, they are called BRANCHIAL (brank-e-le) not BRACHIAL cysts! First branchial ((brank-e-le) cysts are broken up into type 1 and Type 2. Type 1’s generally present as a preauricular cyst, and Type 2’s present at the angle of the mandible (Pasha), or in the “submandibular region” (Pasha). Second Branchial ((brank-e-le) clefts are the most common of the bunch, and tend to be located along the “anterior border of the sternocleidomastoid” (Pasha). Third and fourth branchial cysts are not as common, and are usually located in the lower anterior part of the neck (Pasha). They are often found to be tender and erythematous (Haynes et al, 2015). Dermoid cysts are often soft and painless, and can present anywhere in the neck (Haynes et al, 2015).  

Many different infections can cause neck masses, including bacterial, viral, or even fungal (Schwetscheau and Kelley, 2002). Infections often result in neck masses from reactive lymphadenitis, which is simply swelling of the lymph nodes in response to an infection (Fried, 2020). Some common viral infections include Cytomegalovirus (CMV) or Epstein-Barr virus (EBV) (Haynes et al, 2015). A neck mass may also be the result of a primary bacterial lymph node infection which can include cat-scratch disease, tubercular lymphadenitis,non-tuberculosis mycobacterium  and actinomycosis infections (Fried, 2020). Sometimes, these primary bacterial lymph node infections can lead to abscesses which usually require IV antibiotics and possibly surgical drainage (Schwetscheau and Kelley, 2002). Cultures of these abscess most commonly contain Staphylococcus and Streptococcus species, although they are often polymicrobial (Schwetscheau and Kelley, 2002). 

As mentioned, neoplastic neck masses can be either benign or malignant (Schwetscheau and Kelley, 2002). Benign neck masses are characterized by their slow growth and lack of invasion into nearby tissues and structures (Schwetscheau and Kelley, 2002). Some examples of benign masses include lipomas, hemangiomas, neuromas, and fibromas (Schwetscheau and Kelley, 2002). 

Unfortunately head and neck malignancy is the most common cause of adult neck masses (Tan and Jaya, 2020). For that reason, all adult neck masses should be considered malignant until proven otherwise (Tan and Jaya, 2020). In addition, researchers have begun reporting late presentation of disease that may be related to the Covid 19 pandemic (Tevetoglu et al, 2021). 

Malignant masses can arise as a primary tumour or as the result of metastasis (Schwetscheau and Kelley, 2002). Some examples of primary malignancies include thyroid cancer, lymphomas, sarcomas, and salivary gland cancers (Schwetscheau and Kelley, 2002). The most common primary neoplasms of the head and neck are squamous cell carcinomas (Haynes et al, 2015), accounting for approximately 5% of all newly diagnosed cancers worldwide annually (American Academy of Otolaryngology - Head and Neck Surgery, 2021). Metastatic disease from primary head and neck malignancies follow a well delineated pattern of spread (Schwetscheau and Kelley, 2002). The majority will spread to the lateral neck, however, cancers of the oral cavity usually spread to the submandibular triangle (Schwetscheau and Kelley, 2002).

Presentation: 

Patients or their family members may notice a mass on their neck, or alternatively, one may be discovered on routine physical examination (Fried, 2020). There are many different signs and symptoms that may accompany the mass, which will help to determine the etiology of the mass. Neck masses are often the only complaint of a patient with a head and neck cancer (Tan and Jaya, 2020). Due to this, the diagnosis of a head and neck cancer is often delayed up to 180 days (Tan and Jaya, 2020). A delay in an otolaryngology referral has been shown to be associated with a three-fold increase in mortality (Tan and Jaya, 2020). 

History:

When taking the history of present illness, or HPI, you should ask your patient how long the mass has been present, and if they are experiencing associated pain (Fried, 2020). Acute symptoms including fever, cough, or sore throat, suggest aden opathy as the result of an upper respiratory tract infection (Schwetschenau and Kelley, 2002). 

Some red flag symptoms suggestive of malignancy that you should look out for when taking your patient’s history, include: the mass being present for over two weeks, voice changes, dysphagia, odynophagia, ipsilateral otalgia, nasal obstruction or epistaxis (Tan and Jaya, 2020). Unexplained weight loss or loss of appetite are also considered red flags for malignancy (Tan and Jaya, 2020). Risk factors for cancer should be identified, including alcohol or tobacco use, chronic oral candidiasis, or poor oral hygiene (Fried, 2020). However, the size, duration of the mass, and the patient’s age are the most important predictors of malignancy (Schwetschenau and Kelley, 2002). 

In regards to your patient’s  past medical history, be sure to ask about HIV or tuberculosis diagnosis, or risk factors for these diseases (Fried, 2020), as well as, any previous head and neck malignancy, or head and neck cutaneous lesions (Tan and Jaya, 2020). Also be sure to ask your patients about any other medical conditions, and if they are taking any medications (Schwetschenau and Kelley, 2002). 

Numerous cancers can metastasize to the neck, therefore, a complete review of systems is extremely important in determining the diagnosis of the mass (Fried, 2020). This review of systems should ask about any symptoms of chronic disease including fever, weight loss and malaise (Fried, 2020). 

Physical Exam:

Physical examination begins with inspecting the patient’s skin for premalignant or malignant lesions from chronic sun exposure (Schwetschenau and Kelley, 2002). After inspection, a full head and neck exam should be completed to look for a source of the mass.

First, otoscopy should be performed. If a sinus or fistula is found within or near the ear canal, this could indicate a 1st branchial cleft anomaly,  which as we discussed, is a common congenital neck mass (Schwetschenau and Kelley, 2002). 

The oral exam should involve palpating the base of the tongue, tonsils, the floor of the mouth, and the salivary glands, to look for masses (Fried, 2020). Teeth should be percussed in order to assess for tenderness, commonly seen with a root infection (Fried, 2020). When doing the oral exam, ensure to check for ulcerations, asymmetries (especially in the tonsillar fossa) and submucosal swelling (Schwetschenau and Kelley, 2002). It is important to remember that the most common malignancy is squamous cell carcinoma, which affects the mucosal surface, and therefore will usually present with a non-healing ulcer.

The thyroid should be inspected for any midline masses, both at rest and with the patient swallowing water. Then the thyroid should be palpated for any nodules or irregularities, again both at rest and with the patient swallowing water. A thyroid mass should move with the larynx when swallowing occurs. 

From an endoscopic perspective, the nasal passages, middle meatus, nasopharynx, and larynx should be examined with a flexible endoscope. (Schwetschenau and Kelley, 2002). 

When it comes to the characterization of the neck mass itself, it is very important to determine the location of the mass as it provides insight into the etiology (Tan and Jaya, 2020). Note: Often, otolaryngologists talk about “the levels of the neck” and this is something to be aware of when discussing neck lymph nodes! Where lymph nodes are located in the neck affects treatment, and helps the surgeon determine the type of neck dissection that will be required (entsecrets 4th edition)  The neck can be divided into six sections: Level 1 includes the submental and submandibular triangles, levels 2,3 and 4 include the upper, middle and lower internal jugular chain, level 5 includes the posterior triangle, and level 6 includes the anterior compartment (Tan and Jaya, 2020). 

The patient’s neck should be palpated to evaluate the consistency of the mass, the size of the mass, the presence and degree of tenderness, and whether the mass is fixed or mobile (Fried, 2020). Some findings that indicate that the mass is more likely to be malignant include fixed masses, size greater than 1.5cm, firm, and accompanied by overlying skin lesions such as ulceration (Tan and Jaya, 2020).  

Diagnosis, Treatment and Management:
The diagnosis of the neck mass is heavily guided by history and physical examinations, which in turn will determine the appropriate management plan. As mentioned, neck masses most commonly fit into one of three broad categories, being a congenital anomaly, an infectious or inflammatory condition, or a neoplasm (Schwetschenau and Kelley, 2002). 

If it is felt that the mass is infectious in nature, it is reasonable to try a short course of broad spectrum antibiotics. However, it is important to remember that in the adult population, these neck masses should be treated as malignancy until proven otherwise. The mainstay of workup includes a fine needle aspiration biopsy and a CT scan of the neck. Depending on the findings on physical exam, that will also guide the next steps. For instance, if the patients has a thyroid nodule as well, an ultrasound guided fine needle biopsy of the nodule would be warranted. 

Given that tobacco and alcohol use are risk factors for the development of head and neck cancers, physicians should ensure to educate their patients on the risks involved with these habits. Physicians can also provide patients with smoking cessation resources. 

Patients should also be educated on proper oral hygiene, as poor oral hygiene is a risk factor for head and neck cancer.

Additionally, physicians should encourage their patients to receive routine vaccinations against bacterial and viral infections. This will decrease the chances of developing an infectious neck mass. 

One infecion of significant importance when it comes to head and neck cancers is human papilloma virus (HPV). The presence of HPV–positive oropharyngeal cancer has more than tripled from 19% to 66% between 1987 and 2006 (Tan and Jaya, 2020). In fact, HPV is the most common sexually transmitted infection in America (Centres for Disease Control and Prevention, 2021). Patients with HPV-positive head and neck cancer are often younger than those with HPV-negative head and neck cancers, and the masses are often asymptomatic and frequently cystic (Tan and Jaya, 2020). For these reasons, HPV- positive head and neck cancer is often misdiagnosed, or is diagnosed late (Tan and Jaya, 2020). Therefore, the HPV vaccine is recommended to protect against HPV-related infections and cancers (Centres for Disease Control and Prevention, 2021). It is important to note that patients diagnosed with HPV related oropharyngeal squamous cell carcinoma tend to have better outcomes than those with the non-HPV version of the disease (Taberna et al, 2017)

When it comes to treatment of head and neck cancers, there are a few different options for treatment. Treatment of malignant lesions can include radiation, and/or chemotherapy, and/or surgery. 

If surgery is required, there are a variety of ways that the resulting wounds may be closed. One important concept in Otolaryngology is The Reconstructive Ladder. The Reconstructive ladder consists of a “ladder” of options for skin defect closure, starting with the most basic and then moving up to more advanced closure options (pasha). The steps of the Reconstructive ladder are as follows: 

1. Secondary Intention 

2. Primary Intention 

3. Split-thickness skin graft

4. Full thickness skin graft

5. Local Flaps 

6. Regional Flaps

7. Free Flaps (ENT Secrets)

Final Tips and Tricks:
A malignancy work-up should be started for patients over the age of 40 and presenting with a persistent neck mass (Haynes et al, 2015).

Consider the location of neck masses along with the patient’s history to narrow your differential diagnosis.

Thank you so much for listening to our podcast! We hope you’ll tune into our next episode!

Thank you to Aileen Feschuk for leading authorship of this episode.

We would like to extend our sincerest thanks to the Saint John Regional Hospital Department of Surgery within the Horizon Health Network for their generous support. Please head to our website at www.theotoapproach.com for our show notes, and to sign up for our newsletter to stay up to date with our latest episodes. 

References 

Amos, J., Shermetaro, C. 2021. Thyroglossal Duct Cyst. Stat Pearls. 

https://www.ncbi.nlm.nih.gov/books/NBK519057/

Fried, M.P. 2020. Neck Mass. Merck Manual. 

https://www.merckmanuals.com/en-ca/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-nasal-and-pharyngeal-symptoms/neck-mass 

Haynes, J., Arnold, K., Aguirre-Oskins, C., Chandra, S. 2015. Evaluation of Neck Masses in Adults. American Family Physician 9(1): 698-706. 

https://www.aafp.org/afp/2015/0515/p698.html 

Human Papillomavirus (HPV) Vaccine. Centres for Disease Control and Prevention. 2020. 

https://www.cdc.gov/vaccinesafety/vaccines/hpv-vaccine.html 

Neck Mass in Adults: Guideline for Evaluation Provides Framework for Timely Diagnosis. American Academy of Otolaryngology- Head and Neck Surgery. 2017.

https://www.entnet.org/content/neck-mass-adults-guideline-evaluation-provides-framework-timely-diagnosis 

Schwetschenau, E., Kelley, D. J. 2002. The Adult Neck Mass. American Family Physician 66(5): 831-839. 

https://www.aafp.org/afp/2002/0901/p831.html 

Taberna, M., Mena, M., Pavon, M.A., Alemany, L., Gillison, M.L., Mesia, R. 2017. Human Papillomavirus-related Oropharyngeal Cancer. Annals of Oncology 28(10):  2386-2398. 

https://www.sciencedirect.com/science/article/pii/S0923753419349300

Tan, E., Jaya, J. 2020. An Approach to Neck Masses in Adults. The Royal Australian College of General Practitioners 49(5): 267-270. 

https://www1.racgp.org.au/getattachment/76ca1131-6e95-48ba-be58-1370ae7db0c2/An-approach-to-neck-masses-in-adults.aspx 

Tevetoglu, F., Kara, S., Aliyeva, C., Yildirim, R., Yener, H.M. 2021. Delayed Presentation of Head and Neck Cancer Patients During Covid-19 Pandemic. European Archives of Oto-Rhino-Laryngology. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935695/#:~:text=The%20COVID%2D19%20pandemic%20has,complex%20reconstructive%20procedures%20were%20increased.