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): 613-625 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
Wang SG IA IB IIA IIB VI III VA IV VB Figure 1. The subclassification of neck levels. 614
Diagnosis and Treatment of Neck Masses Table 1. The incidences according to the age and location in neck mass 0~15 16~40 40+ Inflammatory Inflammatory Neoplasia Congenital Congenital Inflammatory Neoplasia Neoplasia Congenital Traumatic Traumatic Traumatic 615
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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
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
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