Approach to Neck Masses &

Thyroid Nodule
By: Amir Reza Honarmand (Chief Stager of Surgery )
Shariati Hospital Tehran
 Differential Diagnosis

• Congenital/Developmental
• Acquired
Inflammatory/Infectious
Neoplastic – Benign or Malignant
primary or secondary
Vascular – AVM, ectatic vessels, aneurysms
Traumatic – Hematoma
 Congenital
Developmental

• Midline
Thyroglossal duct cyst
Dermoid
• Lateral
Brachial cleft cyst – FNA showing debris, cholesterol
clefts / may present with acute infection
Normal anatomy – C1, hyoid, etc.
Muscular – torticollis
 Inflammatory Lesions

• Infectious
Bacterial – strep/staph, cat scratch (bartonella), TB
Fungal – actinomycosis
Viral (HIV, EBV, mumps)
Parasitic – toxoplasmosis
• Inflammatory
Granulomatous disease – sarcoid
Reactive
 Tumor of Neurogenic
Origin

• Neurofibroma
• Schwannoma
• Paraganglioma (carotid body tumor)
 Metastatic Cervical Nodes

• Head and Neck Primary (upper aerodigestive

tract)
• Remote Primary (Virchow’s node)
esophagus, lung, breast, stomach,
renal cell carcinoma
• Malignant Melanoma
• Skin Cancer
• Unknown Primary
 Incidence of Pathologic
Lesions in Neck Masses in
Adults

• Primary thyroid disease 50%

benign, malignant and metastatic
• Metastatic cervical adenopathy 35%
epithelial, other
• Congential 12%
• Inflammatory 3%
 Lymphadenopathy

• Normal nodes <1 cm-1.5 cm

• Inflammatory nodes usually resolve within 2 wks
• First Rule: Any neck mass in an adult patient
must be approached as being neoplastic and
possibly malignant
• Second Rule: Immediate removal of enlarged
lymph node for diagnostic purposes is a
disservice to the patient with metastatic cervical
carcinoma
• Third Rule: Any incision in neck can compromise
future surgery
 Terminology of Lymph Node
Groups
Level I submental, submandibular
Level II upper jugular
Level III middle jugular
Level IV lower jugular
Level V posterior jugular
Level VI paratracheal, perithyroidal
 Drainage Patterns and Neck
Levels

• Level I (Submandibular / Submental)

drain lip, oral cavity and submandibular gland
• Level II (Upper jugular)
drain nasopharynx, oropharynx, parotid, and
supraglottic larynx
• Level III (Mid jugular)
drain oropharynx, hypopharynx, and supraglottic
larynx
 Drainage Patterns and Neck
Levels
• Level IV (Lower jugular)
drain subglottic larynx, hypopharynx,
esophagus,
and thyroid
• Level V (Posterior triangle)
drain nasopharynx and oropharynx
• Level VI (Paratracheal)
drain thyroid and larynx
 Clinical Evaluation of Neck
Mass – History
• age (kids 80% benign, adults over 40
80% malignant), duration, growth,
fluctuation, tenderness, B symptoms,
oral/nasal/ear, skin, voice change, cough,
weight loss, SOB, dysphagia
• Smoking Hx, Personal Ca History,
Previous irradiation, Family Ca Hx
 Fine Needle Aspiration of
Neck Masses

• Sensitivity of 85 – 97% for tumours

• Specificity of 88 – 98%
• Non diagnostic – 8 – 16%
• Useful even for salivary lesions
to rule out
non-salivary pathology
 FNA Results

• Inadequate – repeat – ?US guided

• Lymphoid – “cannot rule out lymphoma”
• SCC – search for primary – flexible
nasopharyngoscopy
• Adenocarcinoma
• Melanoma
• Other – small cell, poorly differentiated ca
• Necrotic – this is suspicious for SCC
 Laboratory Investigations

• Base on suspicion from Hx and Px

• CBC, LDH
• PPD
• CXR for lower neck mass or lymphoma
• Serology (toxoplasma, cat scratch, EBV)
• US – node character – lucency, shape, hilar fat
• Other imaging function of FNA result, eg CT with
SCC, or MRI if unlocalized primary
 Treatment of Metastatic
Squamous Cervical Cancer of
Unknown Primary

• Indication for primary radiotherapy

• Radical neck dissection may be

indicated when open biopsy proven
metastatic squamous carcinoma