Differential Diagnosis of Neck Nodes and Masses

Shape:

• A swelling with the shape of the thyroid = most likely thyroid in origin.
• A globular or round swelling = most likely a cyst.
• A swelling with the shape of parotid = most likely a parotid gland mass.

Multiplicity:

• Multiple lateral neck masses = most likely lymphadenopathy.
• Matted nodes suggest chronic inflammation, TB, metastasis.
• Discrete nodes suggest Hodgkin’s, infectious mononucleosis.

Surface Regularity:

• Irregular = malignant.

Consistency:

• Hard = malignant.

Multiplicity

• Multiple lateral neck masses = most likely lymphadenopathy.
• Matted nodes suggest chronic inflammation, TB, metastasis.
• Discrete nodes suggest Hodgkin’s, infectious mononucleosis.

Mobility:

• Thyroid masses move with swallowing.
• Thyroglossal cyst moves on protruding the tongue.
• Carotid tumor moves horizontally but not vertically.
• Benign masses move in all directions.
• Fixed masses suggest malignant or chronic inflammatory masses.

Surface Regularity:

• Irregular = malignant.

Consistency:

• Hard = malignant.
• Cysts are soft, fluctuant, or tense, e.g., neck abscess.
• Firm or rubbery = Hodgkin’s.

Transillumination:

• Translucent mass = Cyst, e.g., cystic hygroma.
• Expansile/pulsatile cystic mass with thrill or bruit = aneurysm.

The investigations for a patient with a neck lump should be tailored to each individual case.

Minimum investigations to be considered for all patients with neck lumps include:

• FBC
• Neck Ultrasound
• Ultrasound-guided FNAB/fine-needle aspiration cytology (FNAC).
• CXR
• X-ray soft tissue neck

FBC + Differentials + Peripheral Blood Film:

• Lymphocytosis in TB, infectious mononucleosis.
• Leucocytosis in acute pyogenic infection.
• Low PCV anemia of chronic, mitotic disease.

Ultrasound:

• Confirms the extent, consistency, capsule, and surrounding structures.

FNAC:

• Differentiates benign from malignant cellularity.

Specific Investigations:

• CXR: Excludes retrosternal extension, chest metastasis, widening of the mediastinum.
• X-ray Soft Tissue Neck: Assess degree of airway compression, laryngotracheal deviation.

If Neoplastic

Imaging:

• CT-scan
• MRI
• Positron emission tomography (PET) scanning

Biopsy and Examination under Anaesthesia (EUA):

• Direct laryngoscopy and biopsy
• Bronchoscopy, esophagoscopy, panendoscopy

Abdominal Investigations:

• Abdominal ultrasound
• Abdominal CT-scan
• Barium swallow and meal (excludes esophageal or gastric lesion)

Specific Investigations

If Inflammatory or Infective Mass Suspected:

• Plain CXR
• ESR
• C-reactive protein (CRP)
• Bacteriology/Serology
• Mantoux (positive in TB)
• HIV Serology
• Cytomegalovirus (CMV) titres
• Epstein–Barr virus (EBV)

Vascular Tumor:

• CT-angiography
• Duplex Doppler scanning
• Digital subtraction imaging

Thyroid Mass:

• Thyroid function test
• Bone scan

According to the final diagnosis, treatment may involve:

• Treat primary cause
• Conservative
• Medical
• Surgical

Specific Treatments:

• Complete Surgical Excision: Treatment of choice for most benign neck masses.
• Thyroid Mass: Thyroidectomy
• Cystic Hygroma: Injection of sclerosant
• Thyroglossal Cyst: Sistrunk operation
• Pharyngeal Pouch: Crycopharyngeal myotomy or endoscopic stapling (excision of the pouch using diathermy or laser followed by stapling)
• Selective Neck Dissection + Chemoradiation: For metastatic neck mass

Inflammatory Masses:

May be treated by conservative methods with antimicrobial chemotherapy.

Metastatic Neck Mass:

Treatment of the primary site may involve surgical, chemotherapy, radiotherapy, or combination therapy.

Follow-Up:

Regular follow-up for recurrence or complications.

Cure Criteria for Malignant Tumor:

A malignant tumor is considered cured and discharged from the follow-up clinic if there is no recurrence of disease five years after completing treatment.