Neck masses are more common and can generally be classified into three main categories: inflammatory lesions, congenital disorders, and tumors. In turn, tumors are mostly lymph node metastatic cancer, which can be from malignant tumors of the head and neck, but also from malignant tumors of the chest, abdomen, gynecology and extremities. Therefore, the correct diagnosis of neck masses is of great clinical significance.
Inflammatory lesions in the neck
I. Atopic infection
Tuberculous cervical lymphadenitis
This disease is rare in developed countries in Europe and the United States, but is still more common in Asia, Africa and China. The initial infection occurs at an older age, mostly in young people, and is caused by Mycobacterium tuberculosis of human type entering the cervical lymph nodes directly or via bloodstream, but less than 5% of patients have concomitant pulmonary tuberculosis.
Most patients have a long medical history and present to the doctor with a neck mass. The mass may present as a cold abscess and may have skin adhesions. The typical tuberculous neck lesion is a bead-like nodule on one side of the neck, varying in size and activity, or with poorly defined borders due to fusion or adhesion to surrounding tissue inflammation; symptoms such as fever and night sweats may not be obvious, and chest X-ray may not show tuberculosis.
Treatment: Once a clear diagnosis is made, regular, adequate and complete anti-tuberculosis drug treatment should be administered. The course of treatment should be longer than that of tuberculosis, with 1.5~2 years being more appropriate. If the lesioned lymph nodes are large, or the number is large, therapeutic cervical lymphatic dissection, or cervical lymph node dissection can be considered.
Effective anti-tuberculosis drugs should be given immediately after biopsy and cervical lymph node surgery, and the time of wound removal should be appropriately extended for 3~6 days to avoid long-term wound pus flow and fistula formation.
II. Non-specific infection
(A) Acute and chronic lymphadenitis
Mostly secondary to septic infection of the oral cavity, oropharynx, and parapharynx. Acute inflammation has a rapid onset, manifested by red, swollen, hot and painful cervical lymph nodes, some patients may be accompanied by fever, elevated white blood cells, and even abscess formation in the neck; chronic inflammation has a longer duration, and the enlarged lymph nodes appear as painless masses in the neck, which increase slowly.
Treatment: Acute lymphadenitis needs to be treated with effective antibacterial drugs and, if necessary, incision and drainage of pus. Chronic lymphadenitis can be followed and observed after removal of the primary lesion.
(ii) Interstitial infection of the neck
Most often occur in the retropharyngeal, parapharyngeal, and submandibular spaces, secondary to upper respiratory tract infection, tonsillitis, and floor-of-mouth cellulitis. The symptoms are local pain and swelling, and there may be significant swelling and fever in the soft tissues of the neck. In cases of disease caused by odontogenic infections, Streptococcus straw green and Escherichia coli infections are common.
Treatment: Active application of effective antibiotic therapy is the main focus, if necessary, local incision and drainage of pus.
(iii) Infectious mononucleosis
It is thought to be caused by viral infection and is transmitted by contact route. The symptoms are sore throat, enlarged tonsils, enlarged and hard cervical lymph nodes, mild jaundice and aseptic meningitis. Diagnosis is obtained by adsorption test with more than 10% mononuclear cells in blood smear.
Treatment: The disease is self-limiting and generally should not be treated with antibiotics.
Congenital neck masses
I. Thyroglossal cyst
It is the most common midline cyst of the neck, and the disease can be found from the blind foramen of the tongue up to the sternal shank notch.
Clinical manifestations: 90% of cysts in children aged 4 months to 7 years are located in the midline and are painless, moving up and down with tongue extension and swallowing. Cysts located on the surface of the tongue root should be differentiated from the tongue root thyroid; those located in the lower part of the neck should be differentiated from thyroid tumors.
Treatment; surgical excision. The key point is that the cyst must be removed together with the middle part of the hyoid bone during the surgical treatment, otherwise it is easy to recur in the future.
Gill slit cyst
It is generally believed that gill slit cysts are formed due to abnormal development of the 1st to 3rd gill arches during embryonic period, and this disease occurs in young and middle-aged people, accounting for about 60% of males. The swelling in the supracervical region and anterior border of the sternocleidomastoid muscle is cystic in 70% and solid in 30% of cases. About 20% of them show intermittent swelling, because the lymph-like tissue of the cyst wall communicates with pharyngeal lymph, when the upper respiratory tract infection occurs, the cyst also becomes infected and increases in size, after the inflammation subsides, the cyst can return to its original size.
Treatment: surgical excision. The cyst wall should be avoided during surgery to prevent local recurrence after surgery.
Lymphangioleioma
Lymphangioleioma originates from the primitive bursa in embryonic period, and the detached part of lymphatic tissue loses contact with normal lymphatic system, but still maintains the original potential of rapid proliferation.
The pathology can be broadly divided into.
1.Simple lymphangioleioma: It consists of thin-walled lymphatic capillaries with irregular lumen containing lymphatic fluid.
2. Spongy lymphangioleioma: It consists of dilated lymphatic spaces with irregular lumen size and containing lymphatic fluid.
3.Cystic lymphangioleioma: It consists of cystic cavities of different sizes, which are not connected to each other and contain lymphatic fluid.
The incidence of lymphangioleioma is usually seen in infants and children shortly after birth, and is rare in adults. The most common sites are the parotid region, posterior cervical triangle, supraclavicular region, as well as the cheeks, root of the tongue, and floor of the mouth, and generally grow slowly. The masses are irregularly elevated, soft and cystic in texture, with poorly defined borders, but no adhesions to the skin, no pressure pain, and a positive transillumination test. Large lymphangioleioma may compress the trachea and cause wheezing, or involve the mouth and pharynx and cause swallowing and speech disorders.
Treatment: Surgical resection is the mainstay. It is generally considered inappropriate to use sclerotherapy. There are two reasons: 1. the tumor is adjacent to large blood vessels and nerves; 2. the sclerosing agent thickens the cystic wall tissue adhesion, which will increase the difficulty of surgical resection in the future. In recent years, it has been reported in China that Pingyangomycin intra-tumor injection has certain efficacy on cervical lymphadenoma.
Radiation therapy may have some effect, but it is not suitable for young patients. Recurrence within 1 year after treatment accounts for about 10%-15%. The recurrence rate of spongiform lymphadenoma is higher than that of cystic lymphadenoma.
IV. Hemangioma
Hemangioma is a congenital disorder formed by the development of residual mesodermal tissue in the embryonic period. The endothelial-like germ invades into the adjacent tissues and connects with the residual blood vessels after canalization to form hemangioma. Hemangiomas occurring in the head and neck region account for more than 50% of all hemangiomas and are the most common site of occurrence.
They can be clinically classified into four categories
1. Capillary hemangiomas are commonly found in the neck. The tumor is composed of capillaries, which are confined to the skin or subcutaneously and may protrude slightly from the skin surface, lobulated, with clear borders and bright red or purple color, and may be compressed, but rarely turn white when compressed.
2.Cavernous hemangioma is the most common and consists of veins. The tumor is located under the skin, purplish-blue with indistinct boundary, soft in color and turns white when compressed, and the swelling is enlarged when the head is lowered.
3.Tracheal hemangioma is composed of arteries and veins, and it is usually found in the scalp and auricle of adults. The tumor surface skin is purplish red, the temperature is high, there may be obvious pulsation or murmur, local tissues often appear hyperplasia and hypertrophy, there may also be arterial bleeding.
4.Micro-venous hemangioma, also called wine-colored spot, consists of veins. The tumor is in the form of diffuse patches, and is usually found in the head and neck. The tumor is bright red or purplish red, equal to the skin surface, with clear borders, and can be whitened by pressure.
Most hemangiomas invade superficial tissues. If they have invaded deeper tissues, they will show corresponding compression symptoms, such as swallowing disorder, respiratory obstruction, vomiting blood, and upper limb motor sensory disorder.
It is important to perform an aspiration of the tumor during the examination. A definitive diagnosis can be obtained by drawing blood.
Treatment: There are several treatment methods for hemangioma, all of which are effective, depending on the condition of the tumor.
1. Cryotherapy. It is suitable for superficial hemangioma and will not leave scars.
2. Sclerotherapy. Sclerotherapy is injected into the blood vessel to cause embolism. Recently, it has been reported that pinyamycin is used as sclerosing agent in China. If the tumor is large, sclerotherapy can be divided into several times, multi-point, each time 3~5 points, each injection 0.5~1ml, once a week, repeatedly implemented to avoid the side effects caused by an excessive amount of drugs.
3.Radiotherapy. Superficial capillary hemangioma can be treated with X-ray superficial radiation therapy and 32P dressing. Radiation therapy should be used carefully for infants and children to avoid developmental disorders.
4.Surgical treatment. Larger hemangiomas can be surgically removed in stages. Pay special attention to the control of hemorrhage during surgery. After surgery, residual lesions can be treated by radiation or other methods.
5.Drug treatment. In recent years, there are reports of using corticosteroid high-dose shock therapy to treat capillary hemangioma in infants and children, which has certain efficacy on capillary hemangioma. Generally, prednisone 2mg/kg of body weight should not be used, and the total daily amount should not exceed 20mg. once a day, every 3~8 weeks as a course of treatment, gradually reduce the amount and then stop.
Tumor
Neurogenic tumors
Neurogenic tumors include nerve sheath tumors and neurofibromas, as well as chemoreceptor tumors, the former two of which are derived from Schwann cells and the latter from paraganglial cells.
Nerve sheath tumors and neurofibrillary tumors
Nerve sheath tumors are derived from Schwann cells of the nerve sheath, and neurofibromas are also derived from Schwann cells, but the cells are spindle-shaped and have some fibroblastic components. Nerve sheath tumors are perineural and most are isolated masses; neurofibromas are usually not perineural and may be cutaneous or subcutaneous masses. These two types of tumors in the neck are most often seen in the lateral cervical region, most commonly in the vagus nerve, but also in the glossopharyngeal nerve, hypoglossal nerve, cervical plexus, and brachial plexus.
The clinical presentation is a slow-growing lateral cervical spindle-shaped mass that is painless. Horner’s syndrome may be present with compression of the cervical ganglion. Tumors of cervical plexus and brachial plexus origin may present with radiating pain on palpation, as well as a feeling of electric shock and numbness. Tumors originating from the vagus nerve may show cough and change in heart rhythm when palpated. The tumor can move from side to side, but not up and down. CT examination should be performed for deeper tumors to understand the relationship between the tumor and the blood vessels in the neck.
Neurofibromatosis accounts for 10%-15% of malignant tumors, which manifests as rapid growth, pain and abnormal sensation. Usually there is no regional lymph node metastasis, but it can metastasize to the lung via blood channel.
Treatment: Surgery to remove the tumor. If the nerve fibers encircle the tumor, the surgery should try to preserve the nerve fiber components and remove the tumor completely along the envelope.
Chemosensory tumor
Chemoreceptor tumors originate from the paraganglia, including chemoreceptor tumors in the carotid body and jugular venous bulb. The tumors are mostly located at the bifurcation of the common carotid artery, with tight adhesion to the arterial wall, spherical in shape, uniform in cut surface and brownish gray in color.
Clinical manifestations: painless neck mass below the angle of mandible, anterior border of sternocleidomastoid muscle, history can be up to 5~10 years, slow growth, globular or ellipsoidal shape, medium or soft texture, can move from side to side, cannot move up and down. Compression symptoms may appear when the tumor is large: nausea, vomiting and hoarseness when compressing vagus nerve; Horner’s syndrome when compressing cervical sympathetic nerve; hemiglossal atrophy when compressing hypoglossal nerve; sinking soft palate, swallowing disorder and loss of taste sensation in the posterior 1/3 part of tongue when compressing linguopharyngeal nerve.
When the tumor is suspected, carotid angiography should be done, and 3D imaging of CT can be done when available, in order to understand.
1. the relationship between the tumor and carotid artery.
2. the blood flow within the tumor.
3. the extent of the tumor.
4. the presence or absence of cross circulation, etc.
Treatment: Carotid body aneurysm only, usually no treatment can be done. When it is estimated that the tumor cannot be detached, only diagnostic biopsy surgery can be performed. Because the tumor is tightly adhered to the common carotid artery, the common carotid artery needs to be cut off during surgery. The postoperative complications are many and serious, and the mortality rate is as high as 15%~58%.
The indications that require curative surgery are
1. rapid tumor growth, clinical suspicion of malignancy, and estimated resectability.
2.Histological examination confirms malignancy.
3.Patients with good physical condition and small tumor body.
4.The tumor extends into the pharynx and palate and affects the patient’s swallowing, speaking and breathing.
Malignant lymphoma
Malignant lymphoma is a primary malignant tumor of the lymphatic system, a systemic disease that can be found in the head and neck, most commonly in the lymph nodes of the neck, including Hodgkin’s disease HD, non-Hodgkin’s lymphoma NHL.
Clinical manifestations
1. Local symptoms. Single or multiple enlarged lymph nodes in the neck, which may be lobulated or fused, with medium texture, partially movable and without pressure pain; swallowing disorder and respiratory disorder caused by tonsils and nasopharynx swelling; superior vena cava compression syndrome may appear with enlarged mediastinal lymph nodes; hepatosplenomegaly and enlarged abdominal lymph nodes cause gastrointestinal tract compression and obstruction and other symptoms.
2. Systemic symptoms. There are often weakness, low fever, night sweats, anemia, weight loss, fever, sweating, etc., which are called the systemic “B” symptoms of malignant lymphoma.
Diagnosis
If possible, the entire single enlarged lymph node should be removed and diagnostic tests in terms of pathological histology and immunohistochemistry should be performed.
Treatment
It is necessary to see the local manifestation and pay attention to the characteristics of systemic malignant tumor, so as to combine local treatment and systemic treatment, and strive to obtain complete remission after the first treatment.
1. Chemotherapy. The systemic treatment can be combined with MOPP, CHOP, COP and other programs.
2.Radiation therapy. Local treatment means, targeting regional lymph nodes for radiation therapy.
4.Metastatic cancer of cervical lymph nodes
Clinical manifestations of metastatic cancer of cervical lymph nodes
There are abundant lymph nodes in the neck, and the lymphatic confluence of head, neck, chest and abdomen. Most head and neck cancers will metastasize to the lymph nodes in the neck sooner or later along with the lymph flow, and will remain in the barrier formed by the lymph nodes in the neck for several months to years before spreading.
Seventy-five percent of cervical metastases are from head and neck cancers. Approximately 2% to 9% have unknown primary cancer sites and are called occult cancers.
Metastatic cancer of cervical lymph nodes has some manifestations as follows.
1. The lymph nodes are enlarged and medium to hard in texture. In the early stage, they can be movable, but in the later stage, they enlarge, fix and fuse, and invade adjacent organs and skin, and even form skin ulcerated swellings.
2. Most of the metastatic foci in the neck are located in the lymphatic drainage area of the primary focal organ. For example, most of the metastatic foci of nasopharyngeal cancer are in the deep upper cervical lymph nodes, and laryngeal cancer metastasizes to the deep middle cervical lymph nodes.
3.Lymph nodes without redness, heat and pressure pain are mostly discovered by patients accidentally.
Occult tumor
There are often clinical cases in which enlarged lymph nodes are found in the neck and pathologically confirmed as metastatic cancer, but there is no clinical manifestation of the primary cancer tumor, and such primary foci of metastatic cancer are called occult tumor.
In such cases, about 1/3 of patients can find the primary foci after careful examination, and the more common sites are: nasopharynx, tonsils, tongue root, thyroid, upper and lower vocal fold area, floor of mouth, palate, pear-shaped fossa, bronchus, esophagus, breast, and stomach.
Over time, with careful follow-up, about 1/3 of the primary lesions can be found again. These primary lesions often occur in the head and neck region, with the same predilection as described above. The relative incidence has been calculated as 25% for the oropharynx and nasopharynx, 18% for the thyroid, 8% for the laryngopharynx, 10% for other head and neck regions, 21% for the lungs, and 11% for the gastrointestinal tract. Some of them can be hidden for as long as 7 years tonsils,.
In the other 1/3 of occult cancers, the primary focus is undetectable until the patient dies and can only be found at autopsy.
The primary focus can be found based on the location of metastatic lymph nodes in the neck and their pathological histological type. Because the cervical lymph node metastasis of head and neck tumor has certain regularity, the primary site can be inferred from it. For example, if the metastasis in the deep upper cervical lymph node is low differentiated squamous carcinoma, special attention should be paid to the possibility of nasopharynx, especially the submucosal type of nasopharyngeal carcinoma, where the nasopharyngeal area and mucosal surface are generally normal to the naked eye; if the metastasis in the deep middle or lower cervical node is papillary adenocarcinoma, it is most likely to come from the primary papillary adenocarcinoma of the ipsilateral thyroid gland, whose primary foci can be as large as a pinhead or a grain of rice. Left supraclavicular metastatic lymph node with pathological type of adenocarcinoma may come from primary carcinoma of the digestive and respiratory systems
V. Treatment
Radiotherapy
The cervical metastases of hypofractionated squamous carcinoma are firstly selected for radiotherapy at a dose of 40-60Gy, and it is advisable to treat them together with the primary foci such as tonsils, nasopharynx and
Surgery
Radical cervical lymph node dissection is feasible for metastatic squamous carcinoma of cervical lymph nodes, or combined radical surgery with the primary foci.
When the tumor has invaded the internal carotid artery or the common carotid artery, common carotid atherectomy can be considered as an option, but the mortality rate of the operation is high, which has been reported to be 50% in the literature, so this treatment method has not been commonly used.
Parotid Tumor
Tumors in the lower pole of the parotid gland can protrude into the neck, most commonly as mixed tumors of the parotid gland.
Thyroid tumor
A mass located above the superior sternal fossa and near the midline of the neck. It is mostly a solitary nodule, painless, and moves up and down with swallowing.
Lipoma
Lipoma of the neck is a benign tumor, solitary or multiple, common in middle-aged women.
Clinical manifestations are painless masses in the subcutaneous tissue of the neck, soft in texture, with pseudo-volatility and low mobility. If the tumor grows diffusely, it may cause inconvenience in neck movement and even affect breathing.
Treatment: Surgical excision treatment with good prognosis.