Neck Mass (Case 33)

Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Neck Mass (Case 33)

Bradley W. Lash MD and Erik L. Zeger MD

Case: A 24-year-old woman presents for evaluation of a painless lump on her right lateral neck. She noticed it first about 3 weeks ago, and since then it has grown slightly in size. She denies any local symptoms such as hoarseness, otalgia, or difficulty swallowing. She has had no recent infections or high fevers. She denies drenching night sweats or weight loss.

Differential Diagnosis

Infectious or inflammatory lymphadenopathy

Lymphoma (Hodgkin and non-Hodgkin lymphoma)

Squamous cell carcinoma of the head and neck

Thyroid cancer

Benign neoplasms and congenital anomalies


Speaking Intelligently


Clinical Thinking

• The most common causes of neck masses in young adults are infectious/inflammatory, lymphomas, and congenital lesions.

• The incidence of malignancy increases with age and with risk factors such as tobacco or alcohol use.


• The lesion’s onset and growth pattern should be noted. Stable lesions present for a long time are likely to be congenital or benign neoplasms. Conversely, rapidly appearing painful lesions are likely to be infectious/inflammatory or a manifestation of lymphoma.

• Human papillomavirus (HPV) infection increases the risk of head and neck cancer even in those without traditional risk factors such as tobacco or alcohol use.

• Prior radiation exposure (i.e., in the treatment of Hodgkin lymphoma) increases the risk of thyroid cancer.

• Local symptoms such as hoarseness, otalgia, recurrent infections, and dysphagia should be noted.

• Assess for “B” symptoms: fevers, drenching night sweats, and greater than 10% weight loss.

• The lymphadenopathy associated with malignancy (both solid and hematologic tumors) is usually painless; one notable exception is pain associated with alcohol consumption in cases of Hodgkin lymphoma.

• Recent skin infections, dental infections, and sick contacts should be noted.

• A new neck mass in a patient over 40 years old should be considered malignant until proven otherwise.

Physical Examination

• A complete general examination is necessary to search for any source of infection, to look for hepatosplenomegaly, and to evaluate all other nodal areas.

• The location of the enlarged node is helpful. The neck is generally divided into three regions: the anterior triangle, posterior triangle, and central neck. Nodes in each of these areas suggest potential etiologies.

• Examine the mouth, the entire neck including vascular structures, the thyroid, and skin.

Note the characteristics of the mass: a mass that is rock-hard and fixed to adjacent structures is much more likely to be malignant. A tender, rubbery lesion is more likely to be infectious. A pulsatile lesion suggests a vascular aneurysm.

Direct laryngoscopy is part of the evaluation in most patients, especially those with risk factors for carcinoma.

Tests for Consideration

FNA is the first test. It can be performed with local anesthesia and under ultrasound guidance. Using a fine (21-gauge) needle, several passes through the mass are performed, with samples sent for cytologic evaluation. Studies have suggested both a high sensitivity and a high specificity of this test, even for lymphoma.


Open biopsy is performed with complete excision of the mass and allows for the most accurate diagnosis. In cases of lymphoma, tissue examination is critical, as it defines nodal architecture. In cases of Hodgkin lymphoma, the malignant cell represents a small fraction of cells in the lymph node and, therefore, FNA may not establish a conclusive diagnosis.


Bone marrow aspirate and biopsy: If a lymphoma is found, a bone marrow aspirate and biopsy are needed for staging purposes.


Routine laboratory studies rarely lead to a diagnosis but are often helpful. Studies to consider include:


CBC, comprehensive metabolic panel, erythrocyte sedimentation rate, LDH, and testing for various infectious causes such as Epstein-Barr virus (EBV) and HIV.

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While there are other serologic tests available, they rarely add meaningful information. The one exception might be a test to assess for tuberculous infection such as an interferon-γ release assay in patients at risk.




Various imaging studies can be done at the time of initial evaluation or as part of the workup once a diagnosis is established. In cases of lymphoma (both Hodgkin lymphoma and non-Hodgkin lymphoma), the following are helpful:

images CT scan of the chest, abdomen, and pelvis with IV contrast: This allows for complete staging and provides detailed anatomic locations of pathologic involvement.


images PET scanning: Not only does this allow for determining the exact extent of disease, but it can help in determining response to treatment.


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