1.What are the neck masses?
The neck connects the head and the chest, starting from the base of the skull and the entrance of the thoracic cavity, followed by 1-7 cervical vertebrae. The neck includes the pharynx, larynx, trachea, esophagus, thyroid gland, jugular artery and vein, vagus nerve and other important organs. The neck mass is a clinical sign, not a disease, but a symptom of many diseases. The neck is the seat of the upper respiratory tract and upper gastrointestinal tract and is susceptible to external stimulation and injury resulting in infectious masses; the neck is the site of lymphatic aggregation in the head and the whole body, and malignant tumors in all parts of the body, especially in the head and neck, tend to form metastatic masses; the neck tissue is derived from three germ layers of tissue and may form congenital masses during embryonic development; the thyroid gland, the largest endocrine gland in the body, is also located in the neck and forms The largest endocrine gland in the body, the thyroid gland, is also located in the neck, forming thyroid masses; the neck is surrounded by the floor of the mouth and the root of the tongue, and below by the subclavian area, the tip of the pleura and the mediastinum, etc. Swelling occurs in these adjacent areas, often spreading to the neck, and neck masses appear more diverse. Therefore, the etiology of neck masses is more complex, involving internal medicine, surgery, pediatrics, hematology, stomatology, otorhinolaryngology, oncology, etc., which is prone to misdiagnosis and misdiagnosis, resulting in adverse consequences. Neck masses are divided into three categories: neoplastic masses, inflammatory masses and congenital masses according to the cause and pathology.
2.What are the “80% rule” and “seven-word rule” of neck masses?
The incidence of neck masses accounts for about 3-4% of the total body masses. The clinical manifestation of neck masses has a certain regularity, and the 80% rule proposed by Skandalakis: adult neck masses are mostly benign tumors, accounting for about 80%, while malignant tumors are rare; lymph node metastases are the main malignant tumors, accounting for about 80%; malignant tumors metastasizing to the middle and upper neck mostly come from the oral cavity, nasal cavity, pharynx and larynx, accounting for about 80%; malignant tumors metastasizing to the lower 1/3 of the neck and supraclavicular region mostly come from the lower respiratory region. Most of the malignant tumors from the lower respiratory tract, breast and urinary tract account for about 20%. According to the length of the disease Skandalakis summarized three 7 laws, that is, 7d is mostly inflammation, 7 months is mostly tumor, 7 years is mostly congenital mass; these laws only delineate the rough outline, can not be applied mechanically, but should be considered in combination with information from all aspects.
3.Why should we be very alert to neck masses?
Among adult neck lumps, 80% of malignant tumors are lymph node metastases, that is, cancer from other parts of the body is metastasized to the neck, that is, it is not early stage of cancer when found. Among the lymphatic metastases in the neck, 80% are metastases from malignant tumors in the head and neck, which are often referred to as nasopharyngeal, laryngeal, hypopharyngeal, sinus, and thyroid cancers.
The diagnosis of neck lumps requires a comprehensive and detailed physical examination to check the location, size, hardness, whether there is pulsation, pressure pain and radiating pain, and mobility of the neck lumps. Based on the results of physical examination, ultrasound, CT and MRI of the neck can roughly determine the size, location and nature of the mass. Fine needle aspiration cytology examination is an important means to confirm the diagnosis of neck masses, and those who cannot be diagnosed can have a biopsy of the neck masses, and pathological examination of the sections can clarify the nature of the lymph nodes and provide the possible source of the primary foci.
4.What are the congenital masses in the neck?
(1) thyroglossal cyst and fistula: they account for about 70% of congenital masses in the neck and are cystic masses in the anterior midline of the neck, mostly located near the hyoid bone, moving up and down with swallowing and being pulled upward when opening and extending the tongue.
(2) gill slit cyst and fistula: gill slit cyst is located in the lateral part of the neck, mostly unilateral, along the anterior edge of the sternocleidomastoid muscle, touching it as a cystic sensation. Because of the rich lymphoid tissue of the cyst wall and the interconnection with the lymphoid tissue of the pharynx, when infection occurs in the pharynx or the oral cavity, the gill slit cyst also increases in size with infection, and the pain and pressure are obvious, even causing respiratory distress. The cysts may rupture and form fistulas.
(3) Cystic hydatid cyst: It is derived from embryonic lymphatic duct development abnormalities, and 90% of them occur in children under 2 years old. The swelling moves up and down with swallowing when the patient is asked to make swallowing movements. It can be cured by surgical excision.
5.What are the inflammatory masses in the neck?
(1) Parapharyngeal abscess is a deep neck infection involving the carotid sheath in the parapharyngeal space, with a history of pharyngeal infection, red, hot and painful skin of the neck, swelling as hard as a plate, difficulty in opening the mouth and swallowing.
(2) Otogenic neck abscess: history of otitis media mastoiditis, infection spreads under the diastasis at the tip of the mastoid and forms a deep neck abscess.
(3) Acute and chronic lymphadenitis: the primary focus of infection is mostly from the nose, tonsils, pharynx, teeth, etc., causing inflammation of the cervical lymph nodes with local redness, swelling, pain, tenderness, and leukocytosis. Chronic lymphadenitis has a long duration and mild symptoms, often occurring in the deep cervical region of the submandibular area, with small, movable lymph nodes and insignificant pressure pain.
(4) Tuberculous lymphadenitis occurs mostly in young people and can be primary or secondary to tuberculous lesions in the lung and abdominal cavity, manifesting as enlarged lymph nodes with perilymph node inflammation and fluctuating sensation on palpation when multiple lymph nodes adhere to caseous changes, forming cold abscesses, and forming pus fistulas and scarring after breaking the remains. Lymphatic tuberculosis mostly occurs in the submandibular, posterior anterior border of sternocleidomastoid muscle and supraclavicular. Most patients have toxic symptoms of tuberculosis such as malaise, hypothermia, night sweats and emaciation.
(5) Thyroiditis: There are three types of thyroiditis.
(i) acute septic thyroiditis, mostly secondary to degenerative necrosis of thyroid nodules, swollen glands, with pressure pain, reflex otalgia and symptoms of compression of the trachea.
(ii) Subacute thyroiditis, often occurring as a result of epiglottitis or mumps, which may be a viral infection.
(3) Chronic inflammation is an autoimmune disease with increased anti-thyroglobulin autoantibodies in the blood, thyroid tissue infiltrated by a large number of lymphocytes, follicles forming, and diffusely enlarged glands with a smooth surface and a hard texture.
(6) Cervical carbuncle: The skin of the neck is invaded by staphylococcus from the hair follicle causing purulent infection. Due to the thick skin, the infection extends down the fatty column to the cervical fascia and spreads around to enter the hair follicle and multiple pus heads occur, accompanied by severe pain and systemic infection symptoms.
6.What are the benign masses in the neck?
(1) Carotid body aneurysm: Carotid body is a chemoreceptor. Carotid body aneurysms are slow growing, mostly located at the anterior edge of the carotid triangle sternocleidomastoid muscle below the angle of the jaw, and are single round or oval masses, which resemble hard rubber when touched and can move from side to side but are limited to move up and down.
(2) Nerve sheath tumor: It is a kind of benign tumor of nerve tissue, mostly from sympathetic nerve and vagus nerve, with slow growth. It is tough and painless when pressed, mostly located in the anterior cervical triangle, parapharynx and supraclavicular region, and has no adhesion with the skin and surrounding tissues. The tumor can compress the cervical sympathetic nerve and cause Horner syndrome, i.e. droopy eyelid, narrow pupil, sunken eye, ipsilateral facial flushing and less sweating.
(3) Salivary gland mixed tumor: parotid gland mixed tumor is common, manifesting as a mass in front of the ear and under the earlobe; submandibular gland mixed tumor is located in the submandibular triangle, and the symptoms are not obvious, but often a smooth mass on the surface of the submandibular triangle is found by chance.
(4) Thyroid adenoma: Mostly seen in women, it is a single mass that can move up and down with swallowing, and most patients have no symptoms. If thyroid adenoma has insufficient blood circulation and degenerative lesions occur in the nodules, causing cyst formation, it is called thyroid cystadenoma; if papillary changes occur in the adenoma, it is called papillary adenoma, and its malignancy may be greater.
7.What are the characteristics of neck lumps caused by malignant lymphoma?
Malignant lymphoma is a malignant tumor originating from lymph nodes or other lymphoid tissues, mostly found in children aged 5 to 12. It is characterized by painless progressive enlargement of superficial lymph nodes or fever, emaciation and enlargement of liver and spleen. The tumors can be classified into two categories, Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL), based on the cellular characteristics of the tumor tissue. Cervical lymph node enlargement is a common symptom of non-Hodgkin’s lymphoma, and the mass is painless and progressively enlarging. The masses are painless and progressively enlarged. They are hard, movable in the early stages and fuse into a mass in the later stages and are not easily pushed. Lymphomas that occur in the tonsils, nasopharynx, and tongue root can produce symptoms such as nasal congestion, bloody nose, difficulty swallowing, and hearing loss. The lymph node enlargement caused by Hodgkin’s lymphoma is mostly bilateral, and there are systemic symptoms such as fever, hepatosplenomegaly, emaciation and weakness.
8.What are the characteristics of metastatic cancer masses in the neck?
There is a certain pattern of cancer cell metastasis via lymphatic fluid. Nasopharyngeal cancer has the highest rate of cervical lymph node metastasis, which mostly metastasizes to the lymph nodes below the ipsilateral mastoid tip and between the posterior belly of the diastasis, and then expands to the lymph nodes of the internal jugular vein. Metastases to the lymph nodes in the upper part of the internal jugular vein and then to the middle and lower part of the internal jugular vein; thyroid cancer mostly metastasizes to the lymph nodes in the tracheoesophageal sulcus and then to the middle and lower part of the internal jugular vein. The supraclavicular region is the most frequent site of metastatic cancer, the left side is mostly from metastatic cancer of digestive tract, the right side is mostly from metastatic cancer of lung. Breast cancer mostly occurs in the ipsilateral axillary and neck lymph node enlargement. The local characteristics of metastatic lymph nodes are fixed mass, hard texture, fast growth and adhesion to surrounding tissues.
9.Classification of cervical lymph node dissection and classification of cervical dissection
(1) Elective neck dissection (END): This refers to patients who do not have clinically diagnosable lymph node metastasis (cN0) in the neck, but judging from the primary foci (tumor site, pathological differentiation, T classification, previous treatment, etc.), there is a greater possibility of potential lymph node metastasis, and the treating physician decides to perform neck dissection. (2) Therapeutic neck clearance
(2) Neck therapeutic debulking surgery: This procedure is performed for patients with existing lymph node metastases in the neck (cN1~3).