Neck Masses Evaluation

Neck Mass Map - Region & Reason

• Midline Structures:
  • Thyroglossal duct cyst: congenital, moves with tongue protrusion/swallowing.
  • Thyroid: goiter, nodule, carcinoma; often requires USG/FNAC.
  • Dermoid cyst: congenital, doughy consistency, may contain adnexal structures.
  • Submental lymphadenopathy: often due to dental/oral infections.
• Anterior Triangle:
  • Submandibular: Salivary gland (sialadenitis, tumor), regional lymph nodes.
  • Carotid region: 2nd Branchial cleft cyst (anterior to SCM), carotid body tumor (pulsatile), cervical lymphadenopathy.
• Posterior Triangle:
  • Lymphadenopathy: commonest; metastatic (SCC), lymphoma, TB (scrofula).
  • Cystic hygroma (lymphangioma): congenital, soft, transilluminates.
  • Lipoma, neurogenic tumors (schwannoma, neurofibroma).
• Supraclavicular Fossa:
  • Lymphadenopathy: high suspicion of malignancy (e.g., lung, GI).
  • Cystic hygroma, lipoma.

⭐ Virchow's node (left supraclavicular) strongly suggests metastatic gastric cancer; part of Troisier's sign.

The Patient Story - Clues & Feels

• History:
  • Onset/Duration: Acute (inflam/infect) vs. Chronic (neoplasm/congenital).
  • Pain: Painful (inflam) vs. Painless (neoplasm/congenital).
  • Red Flags: Hoarseness, dysphagia, weight loss, night sweats.
  • Risk Factors: Smoking, alcohol, radiation, family Hx cancer.
  • Systemic: Fever (infection), thyroid symptoms.
• Examination ("Feels"):
  • Location: Midline, lateral; specific triangles.
  • Consistency: Soft, cystic, firm, rubbery, hard (malignancy).
  • Mobility: Mobile (benign) vs. Fixed (malignancy).
  • Tenderness: Suggests inflammation.
  • Special Signs:
    • Swallowing movement: Thyroid, thyroglossal cyst.
    • Tongue protrusion movement: Thyroglossal cyst. 📌 (Sistrunk's sign)

⭐ A persistent, firm, enlarging neck mass in an adult, especially >40 years with smoking history, is highly suspicious for malignancy.

Investigation Arsenal - Scan & Sample

• Initial Scan:
  • Ultrasound (USG): First-line. Differentiates cystic vs. solid. Guides FNA.
• Advanced Scans (Staging & Extent):
  • CECT Neck: Defines extent, lymph node status (size >1.5cm, necrosis, ECE).
  • MRI: Superior for soft tissue (e.g., parapharyngeal, perineural spread).
  • PET-CT: For unknown primary, staging.
• Tissue Sampling:
  • FNAC (Fine Needle Aspiration Cytology): Gold standard initial diagnosis. USG-guided for ↑accuracy.

    ⭐ A negative FNAC in a clinically suspicious node (especially for lymphoma) warrants further investigation, often an excisional biopsy.

  • Core Needle Biopsy (CNB): For suspected lymphoma if FNAC non-diagnostic (provides architecture).
  • Excisional Biopsy: Definitive diagnosis if other methods fail (esp. lymphoma). Avoid incisional if malignancy suspected (seeding risk).

Common Culprits - Rogues' Gallery

• Thyroglossal Duct Cyst (TGDC)

  • Midline (or just off-midline), painless, moves with tongue protrusion & swallowing.
  • Embryological remnant.
  • Treatment: Sistrunk procedure (excision of cyst, duct, central hyoid).

• Branchial Cleft Cyst

  • Smooth, non-tender, fluctuant mass on lateral neck, anterior to SCM.
  • Usually 2nd arch origin.
  • Can get infected.

• Lymphadenopathy (LAD)

  • Reactive: Tender, mobile (infection).
  • Malignant: Hard, fixed (metastasis, lymphoma).
  • Tuberculous (Scrofula): Matted nodes, posterior triangle; cold abscess. 📌 "King's evil".

• Dermoid & Epidermoid Cysts

  • Midline, slow-growing, doughy. Contain keratin/skin adnexa.

• Lipoma

  • Soft, lobulated, mobile, subcutaneous. "Slip sign" positive. Benign.

• Carotid Body Tumor (Paraganglioma)

  • Pulsatile mass at carotid bifurcation.
  • Mobile side-to-side, not vertically (Fontaine's sign).
  • "Lyre sign" on angiography.

⭐ Thyroglossal duct cysts, the most common congenital midline neck mass, characteristically move upwards with tongue protrusion.

High‑Yield Points - ⚡ Biggest Takeaways

• Persistent neck mass > 2 weeks warrants investigation, especially in adults.
• FNAC is the primary diagnostic tool for most palpable neck masses.
• Midline masses (children): often thyroglossal duct cysts (move with tongue); Lateral masses (children): branchial cleft cysts or lymphadenopathy.
• Adults > 40: firm, fixed, painless lateral neck mass is metastatic SCC until proven otherwise.
• Left supraclavicular mass (Virchow's node) strongly suggests infraclavicular malignancy (gastric, lung, lymphoma).