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Neck Masses

Definition
The general definition of a neck
mass is any abnormal
enlargement, swelling, or growth
from the level of the base of skull
to the clavicles.

Anatomical Considerations
Prominent landmarks
Triangles of the neck
Lymphatic levels

Anatomical Considerations
The prominent landmarks of the neck
1. Hyoid bone
2. Thyroid cartilage

3. Cricoid cartilage
4. Trachea
5. Sternocleidomastoid
muscles (SCM

Anatomical Considerations
The SCM divides each
side of the neck into
two major triangles,
anterior and posterior.

The anterior triangle is

delineated by
1. The anterior border of the
SCM,
2. The midline,
3. The lower border of the
mandible.

Anatomical Considerations
The borders of the
posterior triangles are :
The posterior border of the
SCM.
The clavicle.
The anterior border of the
trapezius muscle.

Classification of Neck Masses

Common Neck Masses

Inflammantory

Benign leision

Malignant tumor

Congenital

Benign tumor

Metastatic

Primary

Lymphatic nodal leveles/regions

Developed by Memorial
Sloan-Kettering Cancer
Center
Ease and uniformity in
describing regional nodal
involvement in cancer of the
head and neck

Lymphatic nodal leveles/regions

Level I:
Contains the submental
and submandibular
triangles.
Bounded by
the posterior belly of the
digastric muscle
the hyoid bone
the body of the mandible.

Lymphatic nodal leveles/regions

Level II:
Contains the upper
jugular lymph nodes
extends from the level of
the hyoid bone to the
skull base.

Lymphatic nodal leveles/regions

Level III:
Contains the middle
jugular lymph nodes
from the hyoid bone to
the cricothyroid
membrane( ) or
omohyoid muscle(
).

Lymphatic nodal leveles/regions

Level IV:
Contains the lower
jugular lymph nodes
from the cricothyroid
membrane to the
clavicle.

Lymphatic nodal leveles/regions

Level V:
Contains the lymph
nodes in the posterior
triangle
bounded by the anterior
border of the trapezius,
the posterior border of
the SCM, and the
clavicle.

Lymphatic nodal leveles/regions

Level VI:
Contains the lymph
nodes of the anterior
compartment from the
hyoid bone to the
suprasternal notch.
On each side the lateral
border is formed by the
medial border of the
carotid sheath .

Metastasis Location according to

Various Primary Lesions

Level I
Submandibular primary; oral
cavity; lip; paranasal sinuses

Level II
Nasopharynx; oropharynx,
maxillary sinus

Level III
Larynx; hypopharynx; thyroid

Level IV
Subglottic larynx; thyroid; cervical
esophagus

Level V
Thyroid; cervical esophagus;

Level VI
Thyroid; larynx

Staging of the neck

N classification AJCC (1997)
Consistent for all mucosal sites except
the nasopharynx
Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis
Based on extent of disease prior to first
treatment

Staging of the neck

NX:
Regional lymph nodes cannot be assessed

N0:
No regional lymph node metastasis

N1:
a single ipsilateral lymph node, < 3

N2a:
a single ipsilateral lymph node 3 to 6 cm

N2b:
multiple ipsilateral lymph nodes, none more
than 6 cm

N2c:
bilateral or contralateral nodes < 6cm

N3:
a lymph node more than 6 cm in greatest
dimension

Approach of the neck mass

History
Physical examinations
Image studies
FNAB and Biopsy

General Considerations
Patient age
Pediatric (0 -15 years): 90% benign.
Young adult (16 - 40 years): similar to
pediatric.
Late adult (>40 years): rule of 80s.

Location
Congenital masses: consistent in location.
Metastatic masses: key to primary lesion.

General Considerations
Skandalakiss RULE OF 80%
80% of non-thyroid neck masses in adults are
malignant,
80% of these masses are metastastic;
80% of which will come from a primary in the head and
neck.

RULE OF SEVEN
Mass present for seven days is inflammatory.
Mass present for seven months is neoplastic.
Mass present for seven years is congenital.

Diagnostic Steps

History
Physical Examination
Empirical Antibiotics
Diagnostic Tests

Diagnostic Steps
History
Developmental time course
Associated symptoms (dysphagia, otalgia, voice)
Personal habits (tobacco, alcohol)
Previous irradiation or surgery

Physical Examination
Complete head and neck exam (visualize &
palpate)
Emphasis on location, mobility and consistency

Diagnostic Steps
Empirical Antibiotics
Inflammatory mass suspected
Two week trial of antibiotics
Follow-up for further investigation

Diagnostic Steps
Diagnostic Tests
Ultrasonography
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Fine needle aspiration biopsy (FNAB)

Biopsy

Diagnostic Tests- Ultrasonography

Ultrasonography
Useful in
differentiating solid
from cystic masses
and congenital cysts
from solid lymph
nodes and glandular
tumors.

Diagnostic Tests- Computed Tomography (CT)

Computed Tomography (CT):
1. Distinguish cystic from solid lesions .
2. Define the origin and full extent of
deep, ill-defined masses .
3. When used with contrast can
delineate vascularity or blood flow.
4. Detect an unknown primary lesion
5. To help with staging purposes.

Diagnostic Tests- MRI

MRI
Similar information
as CT
Better for upper neck
and skull base
Vascular delineation
with infusion

Diagnostic Tests- FNAB

Any neck mass that is not an obvious

abscess

Persistence after a 2 week course of

antibiotics

Small gauge needle

Reduces bleeding

Seeding of tumor not a concern

Treatment of Neck Mass

Inflammantory

Surgery

Benign leision

Surgery

Radiotherapy
Malignant tumor

Chemotherapy

Treatment of
primary tumor

Classification of Neck Dissections

Standardized until 1991

Academys Committee for Head and
Neck Surgery and Oncology
publicized standard classification
system.

Classification of Neck Dissections

Academys classification
1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)

3. Selective neck dissection (SND)

Supra-omohyoid type
Lateral type
Posterolateral type
Anterior compartment type

4. Extended radical neck dissection

 cervical lymphadenitis

 tuberculosis of cervical lymph nodes

 adenoma of the thyroid

40

mixed tumor of salivary gland

,

B CT MRI

 lymphoma

 metastatic carcinoma

-

Nasopharyngeal carcinoma

 Hypopharyngeal carcinoma

 Laryngeal carcinoma



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Thanks for your attention.