Benign Neck Diseases

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Benign Neck Diseases

Head and Neck Surgery
Author Credentials 

Christine B. Taylor, MD 
Assistant Professor

Philip G. Chen, MD
Associate Professor

University of Texas Health San Antonio
7703 Floyd Curl Drive 
Mail Code 7777
San Antonio, Texas 78229
Phone: (210) 450-0700
Fax: (210) 450-0055
Email taylorcb@uthscsa.edu

Module Summary

The differential diagnosis of neck masses and lesions is broad and encompasses congenital masses, inflammatory/infectious disorders, as well as neoplasms. Workup consists of detailed history and physical examination, imaging, and, frequently needle biopsy. Depending on the diagnosis, treatment consists of antibiotic therapy, aspiration, or surgical excision/resection. The anatomy of the neck is complex, and surgical intervention requires detailed knowledge of the relevant anatomy and adjacent structures as well as knowledge of its complications.

Module Learning Objectives 
  1. Describe the differential diagnosis of benign neck diseases, including neck masses and inflammatory disorders.
  2. Discuss the appropriate workup of neck diseases.
  3. Explain the pathophysiology of benign neck diseases.
  4. Recognize the important anatomic considerations in this area.
  5. Describe the treatment options and algorithms.

 

Embryology

Learning Objectives 
  1. Review embryology of the neck and how it affects the anatomy and potential pathology in this region.
  • Thyroglossal duct anomalies
  • Branchial cleft anomalies
  • Dermoid cysts and teratomas
  • Midline cervical clefts

 

References 
  1. Acierno SP, Waldhausen JHT. Congenital Cervical Cysts, Sinuses and Fistulae.  Otolaryngol. Clin N Am. 2007; 10: 161-176

Anatomy

Learning Objectives 
  1. Describe the anatomy of the neck, including neck levels and important adjacent structures.
  • Neck dissection/Lymph node levels
  • Cranial nerves
  • Vessels

 

References 
  1. Sage HH. Palpable Cervical Lymph Nodes. JAMA. 1958. 496-498
  2. Bryson TC, et al. Cervical Lymph Node Evaluation and Diagnosis.  Otolaryngol Clin N Am. 2012; 45: 1363-1383
  3. Robbins KT, Samant S, Ronen O.  Neck Dissection.  In: Cummings Otolaryngology. 6th Ed. Chapter 119. Philadelphia: Elsevier; 2015. p.1837-1861

 

Pathogenesis

Learning Objectives 
  1. Discuss the differential diagnosis of a neck mass.
  • Congenital (Branchial cleft cyst, thyroglossal duct cyst, vascular lesions, lymphovascular malformations, ranula, teratoma, dermoid cyst)
  • Inflammatory (infectious lymphadenopathy, sialolithiasis, noninfectious inflammatory disorders)
  • Neoplastic (metastatic head and neck carcinoma, thyroid pathology, lymphoma, salivary gland neoplasm, paraganglioma, neurogenic neoplasms/Schwannoma, lipoma)
  1. Describe the disease processes of salivary gland masses/lesions.
  • Parotid neoplasm
  • Submandibular neoplasm
  • Sialadenitis/sialolithiasis 
  1. Identify the various systemic/infectious diseases with manifestations in the head and neck.
  • Viral infection (reactive viral lymphadenopathy, mononucleosis, HIV, mumps)
  • Bacterial infection (Strep/Staph, Atypical Mycobacterial, Tuberculosis, Actinomyces, Cat-Scratch)
  • Noninfectious inflammatory disorders (Sarcoidosis, Sjogren, Kimura, Rosai-Dorfman)
  1. Recognize impact on adjacent structures and be aware of concurrent (systemic) symptoms outside the neck.

 

References 
  1. Nugent A, El-Deiry M.  Differential Diagnosis of Neck Masses.  In: Cummings Otolaryngology. 6th Ed. Chapter 114. Philadelphia: Elsevier; 2015. p.1767-1772
  2. Acierno SP, Waldhausen JHT. Congenital Cervical Cysts, Sinuses and Fistulae.  Otolaryngol Clin N Am. 2007; 10: 161-176
  3. Persky M, Tran T. Acquired Vascular Tumors of the Head and Neck. Otolaryngol Clin N Am. 2018; 51: 255-274 
  4. Jackson NM, Mitchell JL, Walvekar RR. Inflammatory Disorders of the Salivary Glands. In: Cummings Otolaryngology. 6th Ed. Chapter 85. Philadelphia: Elsevier;2015. p.1223-1237
  5. Barzan L, Tavio M, Tirelli U, Comoretto R. Head and neck manifestations during HIV infection. J Larongol Otol. 1993; 107(2):133

 

Basic Science

Learning Objectives 
  1. Discuss how infectious disease processes and immunology play a role in neck disease manifestation.
References 
  1. Goldberg AN, Pletcher SD, Kim T. Head and Neck Manifestations in the Immunocompromised Host.  In: Cummings Otolaryngology. 6th Ed. Chapter 11. Philadelphia: Elsevier; 2015. p.176-200

Incidence

Learning Objectives 

Recognize groups at increased risk of infectious/inflammatory neck conditions, in particular individuals with immune compromise.

References 
  1. Goldberg AN, Pletcher SD, Kim T. Head and Neck Manifestations in the Immunocompromised Host.  In: Cummings Otolaryngology. 6th Ed. Chapter 11. Philadelphia: Elsevier; 2015. p.176-200

Patient Evaluation

Learning Objectives 
  1. Describe the algorithm for workup and evaluation of a patient presenting with a neck mass.
  • Physical exam
  • Testing
  1. Distinguish when to suspect malignancy in the setting of a neck mass.
  2. Formulate a differential diagnosis of neck mass.
  • Congenital (Branchial cleft cyst, thyroglossal duct cyst, vascular lesions, lymphovascular malformations, ranula, teratoma, dermoid cyst)
  • Inflammatory (infectious lymphadenopathy, sialolithiasis, noninfectious inflammatory disorders)
  • Neoplastic (metastatic head and neck carcinoma, thyroid pathology, lymphoma, salivary gland neoplasm, paraganglioma, neurogenic neoplasms/Schwannoma, lipoma)

 

References 
  1. Pynnonen MA et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary. Otolaryngol Head Neck Surg. 2017 Sep;157(3):355-371
  2. Nugent A, El-Deiry M. Differential Diagnosis of Neck Masses. In: Cummings Otolaryngology. 6th Ed. Chapter 114. Philadelphia: Elsevier; 2015. p.1767-1772

Imaging

Learning Objectives 
  1. Review the appropriate indications for imaging in a patient with neck mass or neck disease.
  • Computed Tomography (CT) scan
  • Magnetic resonance imaging or angiography (MRI/MRA)
  • Ultrasound

 

References 
  1. Aygun N, Zinreich SJ.  Overview of Diagnostic Imaging of the Head and Neck. In: Cummings Otolaryngology. 6th Ed. Chapter 8. Philadelphia: Elsevier; 2015. p.104-152
  2. Slough CM, Kamani D, Randolph GW. In-Office Ultrasonographic Evaluation of Neck Masses/Thyroid Nodules. Otolaryngol Clin North Am. 2019 Jun;52(3):559-575
  3. Prasad RS. Parotid Gland Imaging. Otolaryngol Clin North Am. 2016 Apr;49(2):285-312

 

Pathology

Learning Objectives 
  1. Recognize and describe the histologic appearance of the most common benign neck masses.
  2. Differentiate benign from malignant pathology.
  3. Describe expected results from fine-needle aspiration and core-needle biopsy.

 

References 
  1. Zahn KY, Khaja SF, Flack AB, Day TA. Benign Parotid Tumors. Otolaryngol Clin North Am. 2016 Apr;49(2):327-42
  2. Day TA, Weley AF, Joe JK. Neoplasms of the Neck. In: Cummings Otolaryngology. 6th Ed. Chapter 116. Philadelphia: Elsevier; 2015.  p.1787-1804
  3. Smith RB. Ultrasound-Guided Procedures for the Office. Otolaryngol Clin North Am. 2010 Dec;43(6):1241-54, vi
  4. Allin D et al.  Use of core biopsy in diagnosing cervical lymphadenopathy: a viable alternative to surgical excisional biopsy of lymph nodes? Ann R Coll Surg Eng. 2017 Mar; 99(3): 242-244

Treatment

Learning Objectives 
  1. Explain medical and nonsurgical treatment options for benign neck diseases.
  • Observation
  • Antibiotics
  1. Identify when surgical intervention is necessary.
  • Fine-needle Aspiration/Core needle biopsy 
  • Needle drainage/Incision and drainage
  • Excision/Resection of mass/lesion

 

References 
  1. Pynnonen MA et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary. Otolaryngol Head Neck Surg. 2017 Sep;157(3):355-371
  2. Fairbanks DNF. Guide to Antimicrobial Therapy in Otolaryngology – Head and Neck Surgery. 13th Edition. Alexandria VA: American Academy of Otolaryngology – Head and Neck Surgery Foundation. 2007
  3. Jackson NM, Mitchell JL, Walvekar RR. Inflammatory Disorders of the Salivary Glands. In: Cummings Otolaryngology. 6th Ed. Chapter 85. Philadelphia: Elsevier; 2015. p.1223-1237
  4. Smith RB. Ultrasound-Guided Procedures for the Office. Otolaryngol Clin North Am. 2010 Dec;43(6):1241-54, vi.

 

Pharmacology

Learning Objectives 
  1. Review the antimicrobial agents currently used to treat neck infections.
  • Beta-Lactams (penicillins, cephalosporins, carbapenems)
  • Vancomycin
  • Clindamycin
  • Tetracyclines
  • Fluoroquinolones
  • Metronidazole
  • Antivirals

 

References 
  1. Fairbanks DNF. Guide to Antimicrobial Therapy in Otolaryngology – Head and Neck Surgery. 13th Edition. Alexandria VA: American Academy of Otolaryngology – Head and Neck Surgery Foundation. 2007

Surgical Therapies

Learning Objectives 
  1. Explain the neck dissection procedures and their attendant indications, risks, and complications.
  2. Summarize needle aspiration procedures for diagnosis and treatment.
  3. Describe the Sistrunk procedure.
  4. Discuss the various approaches for treating congenital neck masses.
  5. Review the treatment modalities of vascular tumors of the head and neck.

 

References 
  1. Robbins KT, Samant S, Ronen O. Neck Dissection. In: Cummings Otolaryngology. 6th Ed. Chapter 119. Philadelphia: Elsevier; 2015. p.1837-1861
  2. Smith RB. Ultrasound-Guided Procedures for the Office. Otolaryngol Clin North Am. 2010 Dec;43(6):1241-54, vi
  3. Oomen KPQ, Modi VK, Maddalozzo J. Thyroglossal Duct Cyst and Ectopic Thyroid: Surgical Management. Otolaryngol Clin N Am. 2015; 48: 15-27
  4. Acierno SP, Waldhausen JHT. Congenital Cervical Cysts, Sinuses and Fistulae. Otolaryngol Clin North Am. 2007 Feb;40(1):161-76, vii-viii
  5. Persky M, Tran T. Acquired Vascular Tumors of the Head and Neck. Otolaryngol Clin N Am. 2018; 51: 255-274 

 

Rehabilitation

Learning Objectives 
  1. Recognize that patients may require shoulder rehabilitation after neck procedures.
References 

Richmon JD, Roediger FC, Eisle DW. Complications of Neck Surgery In: Cummings Otolaryngology. 6th Ed. Chapter 120. Philidelphia; Elsevier; 2015. p.1862-1871

Case Studies

  1. 45-year-old female with right neck mass.  Patient has a history of cough with abnormal chest x-ray, fatigue and skin lesions over her lower extremities.  She does not smoke.  On examination, mass is located at the right angle of mandible and is somewhat diffuse and the entire parotid gland appears to be involved.
  • Discuss the workup and diagnosis of inflammatory conditions of the neck/salivary glands.  What imaging would you order?
  • Discuss treatment options
  1. 18-year-old otherwise healthy male with painless midline neck mass that occasionally swells.  It does not drain and may have grown slightly over the past few years.  On examination, mass is firm but mobile, and does move with tongue protrusion.
  • What further workup (including imaging) would you order?
  • What treatment options would you discuss with patient and family?  Describe surgical steps in detail.
  1. 37-year-old male with left neck mass.  The mass is painless.  Patient is not a smoker and denies any other symptoms.  On exam, mass is mobile in anterior-posterior direction but not in the superior-inferior direction.  CT imaging was performed and demonstrated splaying of the internal and external carotid artery.
  • What workup would you perform at this point?  Is biopsy indicated?
  • What characteristic findings do you expect to see on histopathology? 
  • Discuss treatment options (both surgical and nonsurgical).  Discuss any pertinent perioperative considerations.

 

Complications

Learning Objectives 
  1. Describe the complications of untreated neck mass or inflammatory/infectious neck diseases.
  2. Review the complications associated with surgery in the neck (neck dissection) and describe the important structures at risk during these procedures.

 

References 
  1. Jackson NM, Mitchell JL, Walvekar RR. Inflammatory Disorders of the Salivary Glands.  In: Cummings Otolaryngology. 6th Ed. Chapter 85. Philadelphia: Elsevier; 2015. p.1223-1237
  2. Richmon JD, Roediger FC, Eisle DW.  Complications of Neck Surgery. In: Cummings Otolaryngology. 6th Ed. Chapter 120. Philadelphia: Elsevier; 2015. p.1862-1871
  3. Robbins KT, Samant S, Ronen O.  Neck Dissection.  In: Cummings Otolaryngology. 6th Ed. Chapter 119. Philadelphia: Elsevier; 2015. p.1837-1861

Review

Review Questions 
  1. What are the main categories of benign neck masses?
  2. How does the neck structure development lead to congenital neck masses?
  3. When is neck ultrasound indicated in workup of a neck mass or lesion?
  4. Describe the nonsurgical management of benign neck disease/neck masses.
  5. Describe the relevant neck anatomy, and considerations in neck dissection surgery.

 

References 
  1. Pynnonen MA et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary. Otolaryngol Head Neck Surg. 2017 Sep;157(3):355-371
  2. Nugent A, El-Deiry M. Differential Diagnosis of Neck Masses. In: Cummings Otolaryngology. 6th Ed. Chapter 114. Philadelphia: Elsevier; 2015. p.1767-1772

 

Resources 

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