Neck Masses: Differential Diagnosis

Neck Mass Basics - Knotty Neck Nav

• Anatomy Overview:
  • Neck Triangles: Anterior & Posterior; key subdivisions.
  • Lymph Node Levels: I-VII.
• General Classification (📌 CIN):
  • Congenital (e.g., thyroglossal, branchial cysts)
  • Inflammatory/Infectious (e.g., lymphadenitis)
  • Neoplastic (benign/malignant)
• Key History Questions:
  • Age, duration, progression (rapid growth?)
  • Associated symptoms: Pain, fever, dysphagia, hoarseness, weight loss.

⭐ A persistent, firm, enlarging neck mass in an adult >40 years, especially with smoking/alcohol history, is considered metastatic malignancy until proven otherwise (often SCC from upper aerodigestive tract).

Congenital & Developmental Lumps - Kiddie Knobs

• Thyroglossal Duct Cyst:
  • Midline, elevates on tongue protrusion/swallowing.
  • Sistrunk procedure for excision.

  ⭐ Most common congenital neck mass overall.

• Branchial Cleft Cyst:
  • Anterior border of SCM.
  • Usually smooth, fluctuant; may fistulate.
  • 📌 2nd arch most common (Type II).
• Dermoid Cyst:
  • Midline (common), can be lateral.
  • Doughy consistency, non-tender. Contains adnexal structures.
• Cystic Hygroma (Lymphangioma):
  • Posterior triangle (classic), can be extensive.
  • Soft, compressible, brilliantly transilluminates.

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Inflammatory & Infectious Swellings - Fiery Swellings

• Reactive Lymphadenopathy: Most common. Tender, mobile nodes.
• Infectious Lymphadenitis:
  • Tuberculous: Scrofuloderma, matted nodes, cold abscess.

    ⭐ Matted lymph nodes are a classic sign of tuberculosis.

  • Bacterial: Staph/Strep. Acute, tender.
  • Viral: IMN (EBV), CMV. Posterior triangle common.
  • Cat Scratch Disease: Bartonella henselae. Tender nodes post-scratch.
• Deep Neck Space Infections: ⚠️ Airway risk!
  • Ludwig's Angina: Submandibular, brawny induration, tongue elevation.
  • Parapharyngeal Abscess: Trismus, medial pharyngeal bulge.

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Neoplastic Neck Masses - Danger Lumps

• Benign: Lipoma, Fibroma, Neurogenic tumors (Schwannoma, Neurofibroma), Salivary gland pleomorphic adenoma.
• Malignant:
  • Metastatic Squamous Cell Carcinoma (SCC): Most common in adults; aerodigestive primary.
  • Lymphoma: Hodgkin's & Non-Hodgkin's (B symptoms: fever, night sweats, weight loss).
  • Thyroid Cancer: Papillary (most common type), follicular, medullary, anaplastic.
  • Salivary Gland Malignancies.
• Red Flags ⚠️: Hard, fixed, rapidly growing, age >40 yrs, smoker/drinker history, B symptoms (unexplained fever, night sweats, weight loss), cranial nerve palsies, overlying skin changes (ulceration, discoloration).

⭐ Most common malignant neck mass in adults: Metastatic Squamous Cell Carcinoma, often from an upper aerodigestive tract primary (e.g., oropharynx, larynx).

Diagnostic Pathway - Unraveling Knots

• Clinical Exam: Systematic (Inspect, Palpate: Site, Size, Consistency, Fixity, Nodes).
• Key Investigations:
  • USG: Cystic vs. Solid.
  • FNAC: Cornerstone for initial tissue diagnosis.
  • CT/MRI: Defines extent, relations.
  • Biopsy: If FNAC inconclusive.
  • Panendoscopy: For suspected occult primary SCC.

⭐ FNAC is the first-line investigation for most neck masses after clinical examination.

High‑Yield Points - ⚡ Biggest Takeaways

• Thyroglossal duct cyst: Most common pediatric midline neck mass; moves with tongue protrusion.
• Branchial cleft cyst: Common pediatric lateral neck mass, anterior to sternocleidomastoid.
• Supraclavicular mass (Virchow's node): Suggests metastatic malignancy from abdomen/thorax.
• Carotid body tumor: Pulsatile lateral neck mass at carotid bifurcation.
• Malignancy suspicion: Firm, fixed, rapidly growing mass in adults.
• Cystic hygroma: Lymphatic malformation, soft, transilluminates, often congenital.
• Tuberculous lymphadenitis: Matted nodes, chronic, may form sinus tract; common in endemic areas like India.