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The patient's age, the location, size and duration of the mass, the patient's overall medical history and associated signs and symptoms are critical components in the evaluation of a patient with a neck mass neck masses, swollen gland, lymphadenopathy, adenopathy, neck lump. Inflammatory lymphadenopathy and congenital disorders occur more frequently in children, whereas malignancies are more common in adults. Location and number of masses present are important factors in the assessment. The onset of the mass can also be of great significance. Inflammatory lesions usually arise over several days, whereas malignancies tend to grow over a period of weeks to months, and congenital or developmental masses are often
Physical examination requires a thorough evaluation of the mass and a complete head and neck examination. The size and location of the neck mass should be documented, and evaluation for associated ery-thema, fiuctuance, and tenderness should be performed. An assessment for fixation of the mass to underlying structures and for the presence of a
PEDIATRIC NECK MASSES
The most common etiology of neck masses in children is lymphadenopathy. However, a complete work-up to evaluate for other infectious causes, such as tuberculosis, toxoplasmosis and cat-scratch disease, should be performed. With actino-mycosis, the condition may present with suppurative nodes, forming sinuses with a red hue. Sulfur granules are
the pus. Effective treatment may require prolonged use of penicillin. Occasionally, the lymph node may become necrotic, form an abscess and fail to respond to antibiotics. Appropriate management consists of fine-needle aspiration and culture followed by incision and
Lymphomas are the primary neoplastic cause of neck masses in children. In this setting, the nodes are rubbery, nontender and nonsuppurative. Biopsy and careful evaluation are crucial, and CT scanning can delineate the extent of the mass and the location of major vessels. Uncertainty regarding the consistency (cystic versus solid) of a mass should prompt ultrasono-graphic investigation.
ADULT NECK MASSES
Congenital lesions of the neck often present with recurrent infections of the lesion (Table 20}. Branchial cleft cysts are divided into three types depending on the location of the cyst and tract.4E First branchial cleft cysts are periauricular and are associated with the external auditory canal. Second and third branchial cleft cysts are located anterior to the sternocleidomastoid muscle and drain into the tonsillar bed and pharynx, respectively. In general, a branchial cleft cyst is usually a single mass that may present in children or adults. Pus aspirated from the cyst contains cholesterol crystals on microscopic examination. Treatment involves antibiotics and removal of the mass. Branchial cleft cystsshould be differentiated from
1. Thyroglossal duct cysts. Thyroglossal duct cysts are embryologic remnants of the thyroid gland's tract as it descends down into the neck. These cysts are usually located at the midline and over the hyoid bone or thyroid cartilage. Excision of the cyst along with a portion of the hyoid bone and
2. Dermoid cysts. Dermoid cysts represent masses that enlarge due to accumulation of their sebaceous content. They may become infected. Treatment
Congenital Lesions of the Neck
Branchial cyst
Usually a single purulent mass; cholesterol crystals may be present; located anterior to sternocleidomastoid muscle
Antibiotic therapy; removal of mass
Thyroglossal duct cyst
Represents embryologic remnants of the thyroid gland; located at midline over thyroid cartilage
Excision of cyst along with portion of hyoid
Dermoid cyst
Enlargement due to accumulation of sebaceous content; may become infected
Simple excision
This case is challenging because of the multiple possible etiologies of the patient's neck mass. Evaluation with fine-needle aspiration is important because it can allow for better surgical preparation and may alter management plans. However, fine-needle aspiration may not be diagnostic, and open biopsy may be required. In the case discussed, the origin of the adenopathy may have been from a submandibular tumor; 50 percent of these tumors
In adult patients with a growing neck mass and a history of tobacco use, carcinoma must initially be ruled out. Careful evaluation of all head and neck mucosal surfaces is required to locate the primary source. Again, fine-needle aspiration is often helpful in this regard. Local biopsy and excision should be considered a last resort because some studies have demonstrated that local biopsy is associated with an increase in local carcinoma recurrence. Determining the primary source of carcinoma can be challenging and requires random biopsies of