ENT

BENIGN NECK MASSES

Dra. Maria Karen R. Alcantara - Capuz
091009
Midline
-

Neck Masses
Thyroid nodules
Cervical lymphadenopathy
Thyroglossal duct cyst
Thymus gland anomalies
Plunging ranula

Lateral Neck Masses

Branchial cleft anomalies
Laryngoceles
Dermoid and teratoid cysts
Anatomical Considerations
Prominent landmarks
Triangles of the neck
Carotid bulb
Lymphatic levels
Triangles of the Neck
Anterior cervical triangle
o
Submaxillary (digastric) triangle
o
Carotid triangle
o
Submental triangle
o
Muscular triangle
Posterior cervical triangle
o
Occipital triangle
o
Subclavian triangle
Levels of the Neck
Level I: Submaxillary and Submental
Level II: Jugulo-digastric LN
Level III: Hyoid cricoid
Level IV: Below cricoid
Level V: Posterior triangle
Level VI: thyroid
General Considerations
Age group
o
Pediatric (0-15), young adult (16-40), older
adult (>40)
Location of the neck mass
o
Midline/lateral, anterior/posterior triangle
Characteristic of the neck mass
o
Rapid/slow growth, cystic/solid, tender/nontender, movable/fixed
Evidence of source of infection or malignancy
elsewhere in the head and neck
*tender neck in mass denotes: inflammatory reaction
*CA: fixed, rapid growth
Diagnosis
History
o
Evolution of mass lesion
Physical examination
o
Visualization

Indirect mirror or flexible

endoscopic exam of all mucosal
surfaces of upper aerodigestive
tract
o
Palpation

Help determine location, size and

relationship (fixation)
Indirect tests
Supply information about the physical characteristics
or position of the mass
o
UTZ, CT scan, MRI, angiography
Direct tests

BENIGN NECK MASSES

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Seek histologic diagnosis

o
FNAB, open biopsy

Ultrasound
Distinguish solid from cystic lesions
Angiography
Evaluate vascularity and blood supply of mass, status
of carotid artery
CT/MRI
-

Provide info about physical characteristics,

vascularity and relationship to adjacent structures
CT: relationship to bone

*thyroid mass: UTZ enough, unless entertaining malignancy

Biopsy
-

Fine needle aspiration biopsy (FNAB)

o
Gauge 23 to 25 needle
Needle biopsy
o
Large bore, more possibility of seeding
Open biopsy
o
Incision, excision, wedge

Incision: get small part

Excision: get the whole thing

Differential Diagnosis
Patient age
0-15
years
Freq of dse
Inflammatory
groupings
Congenital
Neoplastic
Traumatic
Location

Congenital

Inflam
Neoplastic

Midline/Anteri
or

Thyroglossal
duct cyst
Dermoid
Laryngocele
Adenitis
Thyroid
Lymphoma

16-40

40+

Inflammatory
Congenital
Neoplastic
Traumatic

Neoplastic
Inflammatory
Congenital
Traumatic

Anterior

Posterior
triangle

Branchial cyst
Thymic cyst
Sialadenopath
y
Adenitis
sialadenitis
Metastatic
Lymphoma

Lymphangioma

Adenitis

THYROGLOSSAL DUCT CYST

Protrude the tongue, mass moves up
Located more superiorly than thyroid mass
o
Top of hyoid
MC congenital anomaly of central portion of neck
Tract of thyroid tissue along pathway of embryologic
migration of thyroid gland from base of tongue to
neck
Intimately related to hyoid bone, elevates wit larynx
when swallowing
Tx: sistrunk operation (excision of the mass along
with the tract and hyoid bone, central portion of
hyoid bone with mass)
DERMOID CYST
Cyst of midline of upper neck or anterior floor of the
mouth
Young patients
Derived from remnants of embryonic skin
Consists of a lumen lined by keratinizing squamous
epithelium
Located adjacent to or within thyroid lobe
Tx: excision

ENT
LARYNGOCOELE
Abnormal dilation or herniation of saccule of larynx
MC submucosal laryngeal mass lesion
Common in players of wind instrument
Enlarges when the patient exhales or blows
BRANCHIAL CYST
MC congenital mass in the lateral neck
o
Anterior triangle
Vestigial remnant of the fetal branchial apparatus
Presents as bulge or sinus tract opening at the
border of SCM
Internal tract or opening of cyst
o
MC: 2nd branchial cleft anomaly
First Branchial Cyst
Type I
Parallel to EAC
Pretragal, post auricular
Connection with TM or malleus>incus
Surgical excision
Type II
Second
-

Sq epithelium and other ectodermal components

Anterior neck, superior to hyoid bone
Courses over the mandible and through the parotid in
variable position to facial nerve
Branchial Cyst
MC
Painless, fluctuant mass in anterior triangle
Inferior middle 2/3 junction of SCM. Deep to
platysma, lateral to Ix, X, XII, between the internal
and external carotid and terminate in the tonsillar
fossa
Surgical treatment may include tonsillectomy

Third Branchial Cyst

Rare <2%
Similar to external presentation to 2nd BCC
Internal opening is at the pyriform sinus, then
courses cephalad to the superior laryngeal nerve
through the thyrohyoid membrane
Surgical removal
4th Branchial Cyst
From pyriform sinus apex to superior laryngeal nerve
LYMPHANGIOMA/CYSTIC HYGROMA
Congenital malformations of L tissue that result from
the failure of the lymph spaces to connect to the rest
of the lymphatic system
Composed of thin walled channels to larger cystic
areas surrounded by fibrous adventitia
*unicystic mass: branchial cleft cyst
*cystic hygroma: contains cystic spaces
-

Presents as a smooth non-tender mass and can be

transilluminated
80% posterior cervical triangle or in the
supraclavicular area
May fluctuate in size as a result of infection or
hemorrhage
Surgical excision

PLUNGING RANULA
Simple ranula unilateral oral cavity cystic lesion
Plunging ranula pierces the mylohyoid muscle
o
There is submandibular mass
Cyst aspirate
Tx: Excision

BENIGN NECK MASSES

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*mucus retention cyst of salivary glands - ranula

STERNOMASTOID TUMOR OF INFANCY (PSEUDOTUMOR)
Firm mass of the SCM, chin turned away and head
tilted toward the mass
Hematoma with subsequent fibrotic replacement
PT is very successful
UTZ diagnose
Myoplasty
TRAUMATIC NECK MASSES
SCM hematoma/fibroma
Pseudoaneurysm or arteriovenoous fistula
CERVICAL LYMPHADENOPATHY
Submandibular triangle anterior 2/3 of tongue
Submental tip of tongue
Level III tonsils, oral cavity, pharynx
MC type of neck mass encountered
Location of enlarged LN provide important clue about
source of primary disease
Tenderness indicate inflammatory
-

3 causes
o
Viral

adenovirus
Bacterial

Staph aureus, Strep pyogenes

o
Mycobacterial
Malignant lymphoma
Metastatic diseases
o

THYROID MASS
Common cause of lymph in the neck
Extremes of ages will point to malignancies
Clinical hx
o
Age
o
Gender
o
Family history
o
Previous thyroid disease
o
Symptoms of compression and rapid growth
o
Hx of prior radiation exposure (papillary
type)
PE
o
Normal thyroid gland difficult to palpate
o
Firm discrete nodules more likely malignant
than diffuse or cystic swellings
o
Abnormal of vocal cords function or
presence of palpable lymph node
->malignancy
DX evaluation
o
Thyroid function test (TSH, FT3, FT4)
o
Thyroid scan- determine function of gland
and determine if nodule is hot or cold
o
UTZ
o
CT scan
o
FNAB (direct test)