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1 Continuing Education Column Differential Diagnosis and Treatment of Neck Masses Soo Geun Wang, MD Department of Otolaryngology, Pusan National University College of Medicine E mail : wangsg@pusan.ac.kr J Korean Med Assoc 2007; 50(7): Abstract Neck mass is a common clinical finding in all age groups. Although most neck masses have the nature of benign processes, malignant diseases must ruled out. Careful medical history, such as the duration of the mass, the presence of pain, history of upper airway infection, contact history of animals, and travel, should be obtained. Thorough physical examination should be also performed. The patients' age and the location, size, and duration of the neck masses are important pieces of information. Neck masses in children (0 to 15 years) are more commonly inflammatory than congenital or developmental and those in young adult (16 ~ 40 years) are more commonly congenital than neoplastic. However, the first consideration in elderly adults (>40 years) should be neoplasia. The location of the mass is particularly important with respect to the differentiation between congenital and developmental masses because such lesions are consistent in their location. For metastatic neck masses, their location may be the key to the identification of the primary tumor. Inflammatory and infectious causes of neck masses, such as cervical adenitis and cat scratch disease, are common in young adults. The progressively increasing size of the mass indicates malignancy, however, a rapid change of size usually suggests an infectious mass. Congenital masses, such as branchial anomalies and thyroglossal duct cysts, should be considered in the differential diagnosis. Neoplasms (benign and malignant) are more likely to be present in older adults. Ultrasonography-guided biopsy is the best diagnostic method for evaluating neck masses. Panendoscopy (nasopharyx, palatine tonsil, base of tongue, piriform sinus, esophagus, stomach, trachea, and lungs) must be performed in all patients of malignant disease. The Open biopsy should be performed only in case of the neck masses which persist beyond four to six weeks after a single course of a broad-spectrum antibiotic or suspects the malignat lymphoma. Keywords : Neck; Neoplasms; Lymphadenitis; Diagnosis; Therapy 613

2 Wang SG IA IB IIA IIB VI III VA IV VB Figure 1. The subclassification of neck levels. 614

3 Diagnosis and Treatment of Neck Masses Table 1. The incidences according to the age and location in neck mass 0~15 16~ Inflammatory Inflammatory Neoplasia Congenital Congenital Inflammatory Neoplasia Neoplasia Congenital Traumatic Traumatic Traumatic 615

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5 Diagnosis and Treatment of Neck Masses 617

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7 Diagnosis and Treatment of Neck Masses 619

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9 Diagnosis and Treatment of Neck Masses Table 2. The primary sites according to the location of metastatic cervical lymph nodess Locations of cervical metastasis Primary sites Upper Submental & Floor of mouth, ant. submandibular of tongue, buccal mucosa Upper jugular Oropharynx, base of tongue Upper jugular, post. triangle Nasopharynx Middle jugular Larynx, hypopharynx, thyroid Lower jugular Cervical esophagus, hypopharynx, thyroid Lower Supraclavicular Lung, breast, stomach, prostate 621

10 Wang SG Neck mass History, P/E Primary site found No primary site found FNA Confirmatory Nonconfirmatory Benign Neoplastic MRI/CT Inflammatory Cystic Lymphoma Carcinoma Primary unknown Medical therapy Surgical resection Flow cytometry FNA MRI/CT Failure to resolve Node excision Surgical resection Endoscopy Guided biopsies Primary site unknown Primary site found Open biopsy Primary site fand neck treated Intracapsular N1 SCC Extracapsular N1, or N2, or N3 Melanoma/adenocarcinoma 1) Neck dissection and observation or 2) Neck dissection and radiation Tx to neck and Waldeyer's ring or 3) Node removal and radiation Tx to neck and Waldeyer's ring Neck dissection and radiation Tx to neck and Waldeyer's ring Neck dissection Figure 2. The algorithm of the evaluation and treatment of neck mass. 622

11 Diagnosis and Treatment of Neck Masses 623

12 Wang SG 11. McGuirt WF. Differential diagnosis of neck masses. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, ed. Otolaryngology Head and Neck Surgery, 4th ed. St. Louis: Mosby Year Book, 2005: Robbins KT, Samant S. Neck dissection. In: Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, ed. Otolaryngology Head and Neck Surgery. 4th ed. St. Louis: Mosby Year Book, 2005: Weber RS, Byers RM, Petit B, Wolf P, Ang K, Luna M. Submandibular gland tumors. Adverse histologic factors and therapeutic implications. Arch Otolaryngol Head and neck Surg 1990; 116: Skandalakis JE, Gray SW, Takakis NC. Tumors of the neck. Surgery 1960; 48: Mancuso AA, Harnsberger HR, Muraki AS. Computed tomography of cervical and retropharyngeal lymph nodes: Normal anatomy, variants of normal and applications in staging head and neck cancer. Part II: Pathology. Radiology 1983; 148: Som PM. Detection of metastasis in cervical lymph nodes: CT and MR criteria and differential diagnosis. Am J Radiol 1992; 158: Bhattacharyya N. Predictive factors for neoplasia and malignancy in a neck mass. Arch Otolaryngol Head Neck Surg 1999; 125: DeVita VT Jr, Jaffe ES, Hellman S. Hodgkin's disease and the non Hodgkin's lymphomas. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer. Principles and Practice of Oncology. 2nd ed. Philadelphia: JB Lippincott Co, 1985: Som PM. Detection of metastasis in cervical lymph nodes: CT and MR criteria and differential diagnosis. Am J Radiol 1992; 158: Yousem DM, Hatabu H, Hurst RW, Seigerman HM, Montone KT, Weinstein GS, Hayden RE, Goldberg AN, Bigelow DC, Kotapka MJ. Carotid artery invasion by head and neck mass: prediction with MR imaging. Radiology 1995; 195: Carter RL, Barr LC, Orien CJ, Soo KC, Shaw HJ. Transcapsular spread of metastatic squamous cell carcinoma from cervical lymph nodes. Am J Surg 1985; 150: Stuckensen T, Kovacs AF, Adams S, Baum RP. Staging of the neck in patients with oral cavity squamous cell carcinomas: a prospective comparison of PET, ultrasound, CT and MRI. J Maxillofac Surg 2000; 28: Lindholm P, Minn H, Leskinen Kallion S, Bergman J, Ruotsalainen U, Joensuu H. Infulence of the blood glucose concentration on FDG uptake in cancer a PET study. J nucl Med 1993; 34: Hautzel H, Muller Gartner HW. Early changes in fluorine 18 FDG uptake during radiotherapy. J nucl Med 1997; 38: Zimmer LA, McCook B, Meltzer C, Fukui M, Bascom D, Snyderman C, Townsend DW, Johnson JT. Combined positron emission tomography/computed tomography imaging of recurrentthyroid cancer. Otolaryngol Head Neck Surg 2003; 128: McGuirt WF, McCabe BF. Significance of node biopsy before definitive treatment of cervical metastatic carcinoma. Laryngoscope 1978; 88: Medina JE. Neck dissection. In: Bailey BJ, Head & Neck Surgery Otolaryngology, 2nd ed. Philadelphia: Lippincott Raven, 1998: Knight PJ, Mulne AF, Vassy LE. When is lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics 1982; 69: Knight PJ, Reiner CB. Superficial lumps in children : What, When, and Why? Pediatrics 1983; 72: Kikuchi M. Lymphadenitis showing focal reticulum cell hyperplasia with nuclear debri and phagocytosis. Acta Haematol JPN 1972; 35: Lin HC, Su CY, Huang CC, Hwang CF, Chien CY. Kikuchi's disease: A review and analysis of 61 cases. Otolaryngol Head Neck Surg 2003; 128: Lerosey Y, Lecler Scarcella V, Francois A, Guitrancourt JA. A pseudotumoral form of Kikuchi's disease in children: A case report and review of the litera ture. Int J pediatr Otorhinolaryngol 1998; 45: Kim JY, Suh KS, Kim YK. Diagnosis and management of tuberculous cervical lymphadenitis. Korean J Otolaryngol 1995; 38: Day TA, Joe JK. Primary neoplasms of the neck. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schuller DE, eds. Otolaryngology Head and Neck Surgery, 3rd ed. St. Louis: Mosby Year Book, 2005: DeLacure MD, Lee KJ. Carotid body tumors, vascular anomalies, melanoma, cyst and tumors of the jaws. In: Lee KJ, Essential Otolaryngology, 6th ed. Appleton & Lange, 1995: Edgerton MT. The treatment of hemangiomas: With special reference to the role of steroid therapy. Ann Surg 1976; 183: Jackson IT, Carreno R, Potparic Z. Hemangiomas, vascular malformations and lymphovenous malformations: Classification and methods of treatment. Plast Reconstr Surg 1993; 92:

13 Diagnosis and Treatment of Neck Masses 28. Mulliken JB, Glowacki J. Classification of pediatric vascular lesions. Plast Reconstr Surg 1982; 70: Hodge KT, Byers RM, Peters LJ. Paragangliomas of the head and neck Arch Otolaryngol Head Neck Surg 1998; 114: Weymuller EA Jr, Kiviat NB, Duckett LG. Aspiration cytology and cost effective modalty. Laryngoscope 1983; 93: Silver CE, Rubin JS. Cysts and primary tumors of head and neck. In: Silver CE, Rubin JS, eds. Atlas of Head and Neck Surgery, 2nd ed. Churchill Livingstone. 1999: Strasinger SK. Miscellaneous body fluids. Urinalysis and body fluids, 3rd ed. Philadelphia: F. A. Davis Company, 1994: Brewis C, Pracy JP, Albert DM. Treatment of lymphangiomas of the head and neck in children by intralesional injection of OK 432 (Picibanil). Clin Otolaryngol 2000; 25: Orford J, Barker A, Thonell S, King P, Murphy J. Bleomycin therapy for cystic hygroma. J Pediatr Surg 1995; 30: Jaber MR, Goldsmith AJ. Sternocleidomastoid tumor of infancy: two cases of an interesting entity. Int J Pediatr Otorhi nolaryngol 1999; 47: Bedi DG, John SD, Swischuk LE. Fibromatosis colli of infancy: variability of sonographic appearance. J Clin Ultrasound 1998; 26: Myssiorek D, Persky M, Laser endoscop[ic treatment of laryngocele and laryngeal cysts. Otolaryngol Head Neck surg 1989; 100: Booth JB, Brick HG, Operative treatment and postoperative management of saccule cyst and laryngocele. Arch Otolaryngol 1981; 107: Close LG, Merkel M, Burns DK, Deaton CW, Schaefer SD. Asymptomatic laryngocele: Incidence and association with laryngeal cancer. Ann Otol Rhinol Laryngol 1997; 96: Castleman B, Iverson L, Menendez VP. Localized mediastinal lymph node hyperplasia resembling thymoma. Cancer 1956; 9: McAdams HP, Rosado de Christenson M, Fishback NF, Templeton PA. Castleman disease of the thorax: Radiologic features with clinical and histopathologic correlation. Radiology 1998; 209: Keller AR, Hochholzer L, Castleman B. Hyaline vascular and plasma cell types of giant lymph node hyperplasia of the mediastinum and other locations. Cancer 1972; 29: Bowne WB, Lewis JJ, Filippa DA, Niesvizky R, Brooks AD, Brennan MF, Brennan MF. The management of unicentric and multi centric Castleman s disease: A report of 16 cases and a review of the literature. Cancer 1999; 85: Peer Reviewer Commentary 625

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6. ÀÇÇÐ°�ÁÂc00åÇ×¼®Â39~250 Continuing Education Column Differential Diagnosis of Head and Neck Mass Lesions Hang Seok Chang, M.D. Department of General Surgery Yonsei University College of Medicine Yongdong Severance Hospital E