Neck Mass (Case 33)

Pφ

Cervical adenitis is the most common cause of a neck mass in children and young adults. Often a clear source of infection is found (i.e., a recent viral syndrome, cellulitis, or dental infection).

TP

Infectious causes of cervical adenitis often present as acute, painful swelling of one or more nodes. Inflammatory disorders such as sarcoidosis, connective tissue diseases, or salivary gland stones can present with rapidly developing painful lymphadenopathy much like infectious etiologies. History and physical might suggest the diagnosis, but often biopsy (in cases of sarcoidosis), imaging (in cases of stones), or laboratory testing (in cases of autoimmune diseases) are needed.

Infectious causes can be divided into bacterial, viral, fungal, and protozoal causes:

• Bacterial causal agents are often staphylococcal or streptococcal species; however, less common agents such as typical and atypical mycobacteria should be considered in appropriate contexts.

• Viruses are the most common causal agents of infectious lymphadenopathy. Infectious mononucleosis from EBV or atypical mononucleosis from cytomegalovirus (CMV) should be considered. Of note, acute retroviral syndrome in HIV can mimic these disorders.

• Fungal infections are uncommon causes, but histoplasmosis and other pathogens should be considered if appropriate.

• Protozoal causes are unusual, but toxoplasmosis should be considered in the right clinical setting.

Dx

The diagnosis is usually made by history and physical examination, but serologic testing may be necessary. If there is concern for EBV, a monospot test can be ordered. HIV testing should be strongly considered in those with risk factors. Routine cultures are often not necessary.

Pφ

If a cervical biopsy reveals squamous cell carcinoma, it signifies locally advanced disease. While metastatic disease from other primary sites can present with cervical lymphadenopathy, the most common primary site is in the head and neck.

TP

Head and neck cancer often presents in patients over the age of 40 years who have risk factors (tobacco and alcohol abuse) and is often a painless, enlarging mass. Of note, recent data have shown an increase in this disease in younger patients; in these cases, HPV infection seems to be a possible etiology. Often a primary site is found by history or examination, but occult primaries do occur. Localizing symptoms such as otalgia, hoarseness, or dysphagia might point to a primary site.

Dx

The diagnosis is established by complete head and neck examination including panendoscopy (which includes direct laryngoscopy, esophagoscopy, bronchoscopy, and endoscopic evaluation of the nasopharynx). This is most often performed by a surgeon. Imaging studies help to stage the disease and plan surgical resection.

Pφ

Lymphomas are common causes of lymphadenopathy in all age groups. It may be localized or disseminated at diagnosis. Non-Hodgkin lymphoma is more common than Hodgkin lymphoma; however, in some series, up to 80% of patients with Hodgkin lymphoma had cervical node involvement as part of their presentation.

TP

Lymphoma often presents as a painless, slowly enlarging mass. Since in most cases it is a systemic disease at diagnosis, associated symptoms known as “B” symptoms (fever, night sweats, >10% weight loss) may be present.

Dx

The diagnosis is made by biopsy. FNA is able to diagnose lymphoma fairly well. If the FNA is positive for lymphoma or suspicious for lymphoma, a lymph node excision is needed to subtype the lymphoma. Additional diagnostic testing includes CT scan, PET scan, and bone marrow aspiration and biopsy.

Pφ

Benign neoplasms (lipomas, fibromas, neuromas, and hemangiomas) and congenital anomalies (brachial cleft cysts and thyroglossal duct cysts) occur within the neck. While congenital lesions are more common in children, they can be found in adults.

TP

In the case of benign neoplasms, the typical presentation is that of a slowly enlarging mass, which is generally painless. They are typically present for many years and are problematic only if they cause problems with surrounding structures or are cosmetically bothersome.

For congenital anomalies, presentation depends on the type. Classically brachial cysts will be present in the lateral neck, and patients may have a history of recurrent infection or drainage. Thyroglossal duct cysts are found in the midline and move with protrusion of the tongue.

Dx

Often history and physical examination are sufficient to make the diagnosis, although radiographic imaging may be needed. For certain lesions, malignancy can only truly be ruled out at the time of biopsy.

Pφ

Cancer of the thyroid is an uncommon cancer in adults, but the incidence is increasing. It is about four times more common in women than in men. The only consistent risk factor is prior radiation exposure. Thyroid cancer can be divided into three broad histologic categories: differentiated (including papillary, follicular, Hürthle cell), medullary, and anaplastic.

TP

The typical patient presentation is somewhat dependent on histologic type:

• Differentiated: Most commonly found either incidentally on imaging or as a mass in the thyroid. Local symptoms such as hoarseness can rarely occur.

• Medullary: Often found in patients with a positive family history (multiple endocrine neoplasia (MEN) syndromes, RET oncogene mutations). Usually is an asymptomatic mass but can present as paraneoplastic hypercalcemia from calcitonin secretion.

• Anaplastic: Rare, but extremely aggressive. It is locally destructive, often causing airway compromise. It is by definition incurable and stage IV at diagnosis, even if it has not spread beyond the thyroid.

While the incidence is increasing, mortality has not changed for the differentiated types of thyroid cancer. This is probably a manifestation of a lead time bias secondary to incidental diagnosis on imaging.

Dx

After physical examination and/or imaging finds a nodule, the next step is to determine the thyroid status. If a patient has hyperthyroidism, no further workup is needed, as the nodule is unlikely to be cancer. If a nodule is found in a euthyroid or hypothyroid patient, FNA of the lesion should be done.