Differential Diagnosis

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.