54 Neck Swellings
Neck swellings are common findings that present in all age groups and represent a variety of diverse pathologies. The old surgical aphorism, ‘consider the anatomical structures and then the pathology that can arise from these’, is never more appropriate than when one contemplates the causes of a lump in the neck.
54.1 Anatomy
Several structures are palpable in the normal neck. In females, the cricoid cartilage is often the most palpable laryngeal structure; whereas in men, it is the thyroid cartilage. The mastoid tip is readily palpable behind the ear. Between the mastoid tip and the angle of the mandible, the transverse process of the C1 vertebra is sometimes palpable, especially in thin females. This is more likely in elderly patients when osteoarthritis can cause a slight rotation of the cervical spine. This leaves one side of the C1 transverse process prominent (neck slightly rotated to the left leaves a slightly prominent right side of C1 transverse process) and the other side a little retracted. This can be mistaken for a retromandibular parotid mass or hard upper cervical node. The carotid bulb or bifurcation can also be felt pulsating at about the level of the hyoid bone just underneath the sternocleidomastoid muscle (SCM) and can be mistaken as a mass.
Remember the normal glandular structures which are consistent in their location. The thyroid gland is a bilobed structure located along the midline of the neck, either side of the trachea, above the sternal notch and below the cricoid cartilage. The parotid gland is a pyramidal structure found in front of the ear or pinna, and extends from the cheek bone (zygomatic process of maxilla and zygomatic arch) above, down and behind to the mastoid tip, below into the upper neck near the hyoid bone and forward onto the cheek for about 2 to 3 cm. The sub-mandibular gland is located below the posterior half of the mandible and above the hyoid bone. It does not extending beyond the angle of the mandible. It can readily be bimanually palpated intraorally between the fingers of both hands.
The SCM muscle joins the mastoid tip to the sternoclavicular joint and the medial one-third aspect of the clavicle. It is an important landmark dividing the neck into anterior and posterior triangles (
Fig. 54.1).
Within each side of the neck there are located more than 100 lymph nodes, usually impalpable, and distributed mainly along the jugular chain. They are located within each of the five clinically and anatomically described levels of the anterior neck and in the single but divided level in the posterior neck. The posterior border of the SCM separates the anterior neck from the posterior neck. There are other major structures within the neck, such as nerves, blood vessels, muscles, cartilages and bones. Knowledge of their anatomical outline should allow the examiner to consider any abnormal enlargement or swellings in each anatomical location to be included within a differential diagnosis.
Fig. 54.1 Triangles of the neck. SCM, sternocleidomastoid. (Reproduced from Dyleski R, Linstrom C, Pitman M, et al. Anatomy of the neck. Total Otolaryngology. Head and Neck Surgery. 1st ed. New York, NY: Thieme; 2014.)
54.2 Differential Diagnosis
Reaching a diagnosis requires some knowledge of the potential pathology. It is difficult to present an exhaustive list of the potential causes of a neck swelling, but a simple classification is as follows:
• Congenital: lymphangiomas, dermoids, thyroglossal cysts.
• Developmental: branchial cysts, laryngoceles, pharyngeal pouches.
• Skin and subcutaneous tissue: sebaceous cyst, lipoma.
• Thyroid swellings: multi-nodular goitre, solitary thyroid nodule, firm/hard/woody thyroid swelling (possibly anaplastic carcinoma or thyroiditis).
• Salivary gland tumours: benign (e.g., pleomorphic adenoma, Warthin’s tumour) or malignant tumour (e.g., mucoepidermoid, adenoid cystic).
• Tumours of the parapharyngeal space: deep lobe parotid tumour, chemodectoma.
• Reactive neck lymphadenopathy: tonsillitis, glandular fever, HIV.
• Malignant neck node: carcinoma metastases, carcinoma of unknown primary, lymphoma. In practical terms, the diagnosis is reached from the patient’s age, the history, physical examination of the neck, the lump’s location, a thorough examination of the upper aerodigestive tract and the results of appropriate tests and investigations.
54.3 Clinical Assessment
54.3.1 History
The first consideration should be the patient’s age group. In general, neck masses in children and young adults are more commonly inflammatory than congenital and only occasionally neoplastic. However, the first consideration in the older adult should be that the mass is neoplastic. The duration of symptoms is one of the most important historical points. Inflammatory disorders are usually acute in onset and resolve within 2 to 6 weeks. Cervical lymphadenitis is often associated with a recent upper respiratory tract infection. In contrast, congenital masses are often present since birth as a small, asymptomatic mass which enlarges rapidly after a mild upper respiratory tract infection. Metastatic carcinoma tends to have a short history of progressive enlargement. Transient post-prandial swelling in the submandibular or parotid area is suggestive of salivary gland duct obstruction. Bilateral diffuse tender parotid enlargement is suggestive of parotitis, most commonly mumps.
One must also be mindful that associated symptoms both specifically from the mass and from symptoms suggestive of a systemic process such as fever, night sweats, fatigue or weight loss (consider lymphoma) must be sought and documented. Symptoms of a sore throat or upper respiratory tract infection may suggest an inflammatory cervical lymphadenopathy. Persistent hoarseness of voice, sore throat, pain on swallowing, cough and sensation of a lump in the throat are risk symptoms of an upper aerodigestive tract malignancy. The symptoms are particularly relevant in patients who are over the age of 40 years and who smoke cigarettes.
54.3.2 Examination
A full head and neck examination including fibre-optic examination of mucosal surfaces of the pharynx and larynx is important, especially when suspecting a malignancy. The overlying skin colour and texture, and the location, mobility and consistency of a neck mass can often place it within a general aetiological group—congenital, nodal/inflammatory, vascular, salivary, thyroid or possibly neoplastic. Congenital masses may be tender when infected or inflamed, but are generally soft, smooth and mobile. A tender, mobile mass or a high suspicion of inflammatory adenopathy with an otherwise negative examination may warrant a clinical trial of a broad-spectrum antibiotic and a review after 2 weeks. Chronic inflammatory masses and lymphomas are often non-tender and rubbery and may be mobile or feel like a ‘matted mass’ of nodules. In older age groups, the sub-mandibular and parotid glands may become ptotic (droopy) and mimic a neck mass, and can cause concern to patients.
54.4 Investigations
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