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Evaluation of Neck Masses
Evaluation of Neck Masses BLAKE CADY, M.D.
Tissue masses in the neck are a common presentation of disease as seen in the surgeon's office. An easily remembered scheme for rapid clinical evaluation of these masses is helpful in planning diagnostic procedures, considering therapeutic steps, and advising patients as to preliminary diagnosis and prognosis. For simplicity, neck masses may be thought of as unilateral or bilateral, multiple or solitary, and upper or lower. In addition, solitary masses must be categorized as midline or lateral. The surgeon must have several options in mind regarding the neck mass, and several questions must be asked. Is this mass likely to be benign or malignant? If benign, is surgical therapy necessary? If malignant, is this a generalized or regional process? If this is a regional malignant process, should the basic therapy be surgical or nonsurgical? If the therapy is to be surgical, will preliminary histologic diagnosis of the neck mass be necessary? Direct, open surgical biopsy of a neck mass should never be considered until the surgeon has analyzed the mass in relation to such a scheme. Direct surgical biopsy should be performed only if the likelihood of benignancy is extremely high or, if malignancy is considered, the surgeon is prepared to deal with all surgical eventualities at the time of operation, after obtaining a frozen section. Casual biopsy without frozen section and without thorough clinical evaluation and application of critical reasoning is only to be condemned, since valuable surgical dissection planes may be destroyed or, worse, seeded with cancer cells, which may drastically alter recurrence rates and curability. Strong consideration should be given to the use of needle aspiration biopsy of neck masses that are considered potentially malignant when tissue diagnosis is necessary before deciding to operate. Most pathologists familiar with cytology and techniques of the Papanicolaou smear are willing to give reasonably accurate diagnoses on the basis of an aspiration smear from a mass in the neck, for example, lymphosarcoma, epidermoid carcinoma, or carcinoma of the thyroid. More detailed histologic diagnoses may not be obtained, but this much information can provide valuable guidelines as to future surgical management. Thus, the neck mass Surgical Clinics of North America- Vol. 50, No. 3, June, 1970
559
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BLAKE CADY
may be approached directly by radical neck dissection if the biopsy specimen indicates epidermoid carcinoma from the oral cavity or larynx, or it may be approached directly for open surgical biopsy for an accurate description of the particular type of lymphosarcoma after preliminary estimation that it is not an epithelial tumor. In addition, a smear of a carcinomatous node from the thyroid gland is distinctive enough that the surgeon may have valuable preliminary knowledge and may plan appropriate surgical incisions and dissections. First consideration in the evaluation of neck masses should be given to a careful, detailed history. Age, of course, is a good indication of disease, since infants with neck masses have a high frequency of benign or congenital lesions, such as cystic hygromas and occasionally bronchogenic cysts and thyroglossal duct cysts, while young adolescents are likely to have lymphadenopathy on the basis of inflammatory or viral diseases. Teenagers and young adults with neck masses should always be suspected of having lymphosarcoma or carcinoma of the thyroid. Elderly patients are more likely to have epidermoid carcinoma arising in the upper part of the respiratory system or oral cavity and are more likely to display metastatic disease from viscera, such as the lung, stomach, or pancreas. Rapidity of enlargement of a mass, possible fluctuations in size, pain, tenderness, and constitutional symptoms are diagnostic clues. Branchial cleft cysts, thyroglossal duct cysts, and preauricular cysts frequently display fluctuations in size, sometimes with apparent drainage of material onto the skin. Warthin's tumor of the parotid gland frequently has a clear history of size fluctuations consistent with the large amount of lymphoid tissue. Salivary glands with episodes of ductal obstruction usually have a history of more rapid fluctuations in size related to eating. Such size fluctuations may occur with great rapidity, and it is not uncommon for patients with branchial cleft cysts or thyroglossal duct cysts to relate the almost overnight appearance of a mass associated with a respiratory tract infection. Surprisingly, patients with known malignant conditions will relate relatively rapid enlargement of a mass in the neck, when it is apparent that the disease has been present for a considerable period. It should be understood that a mass in the neck that may have been present for some time frequently produces the history of sudden appearance and rapid increase in size and is eventually proved to be metastatic carcinoma. Of course, tenderness is usually associated with inflammatory processes but may herald an acute obstructive phenomenon such as obstruction of a submaxillary duct by calculus or sudden duct obstruction in a thyroglossal cyst. Constitutional reactions are of particular concern in the history because of clues offered in diagnosis. Fatigue, malaise, anorexia, and weight loss most likely indicate generalized disease, whether viral, inflammatory or neoplastic. Constitutional symptoms may indicate an advanced malignant lesion such as carcinoma of the lung or gastric carcinoma with metastases. Neck masses appearing in the presence of constitutional symptoms indicate nonsurgical disease. Thus, the surgical masses that appear in the neck, such as thyroid metastases, epidermoid
EvALUATION OF NECK MASSES
561
cancer metastases, parotid tumors, or benign lesions usually have no constitutional symptoms. Specific complaints referable to the upper part of the respiratory tract or to the digestive system may give clues as to involvement by primary cancer. Thus, all patients should be questioned specifically for the possibility of hoarseness, sores in the mouth, dysphagia, cough, hemoptysis, nasal obstruction, episodes of ear infections, and so forth. All these may offer clues as to malignant lesions in the nasal, oral, pharyngeal, or laryngeal regions. Other aspects of specific interest in the history should include a detailed investigation of smoking habits. It is well known that heavy pipe and cigar smokers have a considerable incidence of oral cavity and pharyngeal epidermoid cancer, while the risk is also present in heavy cigarette smokers. Those patients who chew tobacco or use a quid of snuff habitually eventually undertake considerable risk of carcinoma of the buccal mucosa or oral cavity. Histories of exposure to radiation or to animals and occupational and health histories should be taken, with particular concem to any recent manipulations in the upper oral or respiratory tract cavities such as dental extractions. Radiation therapy even in low doses has been heavily implicated in the development of carcinoma of the thyroid in young adults and should always be investigated in potential thyroid masses. Patients with unusual inflammatory conditions such as cat-scratch fever may occasionally present with cervical adenitis, as may those with certain fungal infections and nonspecific conditions such as sarcoid. This abbreviated outline points out the necessity of taking a detailed history in patients seen with neck masses. The surgeon should be skilled in use of the laryngeal mirror for vocal cord and laryngeal examination as well as for surveys of the nasopharynx. No biopsy of a neck mass that is of indeterminate cause should be undertaken without accurate examination of the larynx, base of tongue, tonsillar fossa, pharyngeal wall, and nasopharynx. Furthermore, accurate and detailed assessment of the oral cavity should be performed by palpation as well as by visual inspection. This necessitates the removal of dentures and the use of a finger cot or a plastic glove to enable every accessible part of the mouth to be seen and touched. The base of the tongue can be inspected by palpation at the conclusion of examination of the oral cavity by sweeping the index finger over its surface after carefully cautioning the patient of the possible sensation of gagging. Bimanual palpation of the cheeks, floor of the mouth, and gingival buccal sulci is also essential in evaluating these areas, particularly for masses occurring in the submaxillary and submental spaces. This aspect of the physical examination is one of the most neglected, based on lack of familiarity with the anatomy and infrequency of the disease. These examinations should be utilized frequently enough on normal patients so that, when necessary, confidence in assessing the findings in the upper digestive and respiratory areas will be adequate. With the patient seated, both sides of the neck should be examined, and the patient should be instructed to turn the head from side to side and to swallow to visual-
562
BLAKE CADY
ize the masses more fully. Palpation should be performed beginning with the jugular chain of lymph nodes from the mastoid process and upper part of the neck to the lower part of the neck and including the other regions of lymphatic tissue, such as the chain of nodes accompanying the spinal accessory nerve and in the supraclavicular fossa lateral to the lower part of the sternocleidomastoid muscle. This can be accomplished most easily by holding the patient's head with the opposite hand and rotating the head slightly to the side opposite the mass to release tension on the sternocleidomastoid muscle. The side of the neck should be palpated both with the flat of the hand and by picking up the sternocleidomastoid muscle between the thumb and fingers to evaluate the tissue beneath and adjacent to the sternocleidomastoid muscle and jugular vein. In addition, with the head tilted toward the side being examined, tension on the supraclavicular fossa and trapezius muscles can be eased so that these regions can be palpated carefully and completely. The course of the carotid vessels should be outlined on each side so that the relation of the masses to the carotid bulb can be determined. The area of the submaxillary and submental spaces is less easily assessed than the jugular region; the physician must examine these spaces bimanually with one finger inserted into the oral cavity. The thyroid area should be inspected in detail by relaxing the adjacent muscles as described and palpating over and around the lower portion of the sternocleidomastoid muscle and adjacent to the upper part of the trachea and lower part of the larynx. Careful palpation directly over the trachea should indicate the location of the thyroid isthmus and offer clues as to the relative size and location of the thyroid gland. Examination of the thyroid can also be performed from behind, frequently offering more subtle evaluation of the thyroid lobes with the flats of the fingers over the lower anterior portion of the neck. Examination of the thyroid should be performed with the patient swallowing or sipping from a glass of water. Masses in the upper midline of the neck should also be assessed in relation to swallowing, as cysts of the thyroglossal duct frequently move in conjunction with the base of the tongue and hyoid bone. Detailed physical examination of the neck masses must be performed, with particular attention to location, consistency, movability, tenderness, size, and configuration. As previously mentioned, the masses must be examined with consideration of the location in either the upper or lower part of the neck, whether they are multiple or solitary, and, if solitary, whether they are midline or lateral. In addition, location in relation to skin should be noted. Are these lesions within or attached to the skin, such as sebaceous cysts, or are they in the subcutaneous fat, such as lipoma? In judging consistency, the physician should estimate masses in regard to a rather poorly defined descriptive terminology: cystic, implying the sensation of fluid under pressure; fluctuant, suggesting fluid not under pressure; inflammatory, indicating a soft and pliable sensation such as might be noted with slightly enlarged but relatively normal lymph nodes; fleshy, as in lymph nodes that are enlarged with the capsule stretched over slightly compressed tissue, giving the sensation of a soft, gum rubber eraser; and hard, giving the impression of distinct firmness not associated with normal tissue.
EVALUATION OF NECK MASSES
563
In particular, branchial cleft cysts and thyroglossal duct cysts tend to have expected cystic qualities. Abscessed lymph nodes with purulent contents may produce a sensation of fluctuation. Enlarged submaxillary salivary glands usually feel soft and fatty with a somewhat irregular, slightly lobulated surface. However, if the submaxillary salivary gland has been chronically enlarged because of a partially obstructed duct, it frequently is the site of chronic inflammatory changes with fibrosis and feels much firmer and on occasion even hard. In the evaluation of patients with epidermoid carcinoma of the oral cavity, such an enlarged gland sometimes cannot be distinguished from a lymph node involved with metastatic cancer. Infectious lymphadenopathy tends to feel soft and fleshy also, but nevertheless has a slightly firmer sensation than that of a normal submaxillary salivary gland. Cervical lymph nodes enlarged as a result of lymphosarcoma tend to have a certain rubbery firmness. In addition, of course, mixed tumors of the parotid gland frequently feel rubbery~ as if the tissue contained within the capsule were under tension . This characteristic is borne out when hemisections of sarcomatous lymph nodes or mixed tumors of the parotid gland are performed; the cut surface of these lesions bulges because of the increased pressure of tissue within the capsule or pseudocapsule. Other parotid lesions may feel either inflammatory, such as Warthin's tumor, which is composed largely of lymphoid tissue, or hard, such as parotid carcinoma, which frequently has the characteristic hardness of an epithelial malignant lesion. It should also be noted that metastatic papillary carcinoma of the thyroid in cervical lymph nodes frequently has the sensation of a soft, fleshy, inflammatory lymph node and is not suspected clinically to be malignant. Finally, a lymph node involved with metastatic epidermoid carcinoma from the upper respiratory or digestive passages has a characteristic hard sensation and, in addition, is frequently fixed to the surrounding structures because of growth through the lymph node capsule and into surrounding tissues. Some neck masses have a bony hardness on palpation and are, in fact, related to relatively normal anatomic structures in the neck. One common bony mass palpated in the upper part of the neck is the transverse process of the second cervical vertebra, which is occasionally prominent just below the mastoid process. If the patient has recently lost weight and the amount of subcutaneous tissue has decreased, this bony mass may easily be felt either by the patient or by the physician. Not only are such bony.masses of a distinctive consistency but they are also naturally completely immobile. On occasion, cervical ribs may be palpated in the middle portion of the neck, and these are distinguished by bony hardness and fixation. The greater cornu of the hyoid bone is hard but fairly movable. Any lymph node more than 2 em. in diameter is most likely to contain a malignant growth. Exceptions to this rule are found in sarcoidosis and in some of the more unusual inflammatory lesions, such as catscratch fever and tubercular adenopathy. The movability of neck masses is of some consequence in differential diagnosis, and during physical examination definite attempts should be made to move these masses in at least two different planes.
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BLAKE CADY
Much information can be gained by this. For instance, neuromas of the vagus nerve and carotid body tumors frequently. can be moved in a horizontal plane but are relatively immovable in a vertical plane. This also might apply to branchial cleft cysts and thyroglossal duct cysts because of the embryonic remnants that tend to fix them in a vertical plane but allow motion in the horizontal plane. Movability, of course, is also related to fixation to surrounding structures that most commonly occurs with inflammatory reactions about the nodes or neoplastic involvement of the tissues surrounding lymph nodes. Movement in relation to swallowing is characteristic of the thyroid gland, and upward movement on protrusion of the tongue is a unique feature of thyroglossal duct cysts. Tenderness most frequently is related to inflammatory changes in neck masses; however, it can also be related to episodes of sudden obstruction even without inflammatory changes, such as an acutely obstructed submaxillary salivary gland duct or an acutely distended branchial cleft cyst. Acute thyroiditis may present as a tender mass in one or both lobes of the gland low in the neck. Masses of nodes in the low jugular chain or in the area near the lymphatic-venous junction will present as fixed masses when involved by metastatic carcinoma originating in the lung, esophagus, or abdominal cavity. Infrequently, advanced breast cancer metastatic to supraclavicular lymph nodes will present as fixed masses in this region. In the upper part of the neck, fixed masses are usually associated with metastatic carcinoma arising in the nasopharyngeal or oral area. The question of fixation of masses is important in evaluating patients for suitability for operation, since the presence of a densely fixed mass in the jugular chain indicates that the lesion is of borderline operability at best and probably is inoperable. The size of the lesion is important, as previously mentioned. However, it should be recognized that multiple small nodes in the neck can indicate metastatic papillary carcinoma of the thyroid or early lymphosarcoma as well as generalized inflammatory lesions of lymph nodes, such as infectious mononucleosis or childhood viral illnesses. The configuration of the mass in the neck, of course, is also important, since lesions that stretch an encompassing capsule tend to assume a rounded configuration, while lesions that develop within a tubular or elongated structure tend to have a linear configuration in part. Thus, branchial cleft cysts and thyroglossal duct cysts frequently give the sensation of tails running off at upper and lower ends of the cyst, indicating attachment to embryologic structures. In addition, neurogenic tumors in the neck frequently have an elongated configuration, indicating origin in a vertical, elongated structure. Enlarged salivary glands tend to have a more irregular over-all configuration than abnormalities of lymph nodes, for instance. In addition, the sensation of a carotid body tumor may be distinctly different, not only because of its adherence to a pulsating structure and its relative fixation vertically but also because of its configuration, which may be more flattened and disc-like than globular. The careful palpation of a pulsatile mass in the neck in older patients frequently will reveal that what was originally thought to be a carotid
EVALUATION OF NECK MASSES
565
aneurysm is a tortuous carotid vessel that has kinked or sometimes nearly twisted upon itself. Frequently the rigid calcific walls of an arteriosclerotic carotid vessel, particularly at the bifurcation of the common carotid artery, may be misinterpreted on hasty examination. A Y-shaped configuration and the sensation of a hard mass that is movable laterally may confirm the fact that this is an arteriosclerotic plaque, which may not have a readily palpable pulse if the vessel is nearly occluded. In the evaluation of specific masses discovered within the neck on physical examination, illustrations of some of the diagnostic points previously mentioned will be helpful. Lesions that have the least likelihood of being surgical in nature are those that are bilateral and lower in the neck. The principal surgical lesions to consider in this area are thyroid masses with or without jugular lymph node enlargement. Adenomatous goiter or chronic thyroiditis may present as masses in both lobes of the thyroid gland and as such, of course, is unlikely to be accompanied by lymph node masses. However, papillary carcinoma of the thyroid that might arise in one lobe frequently has bilateral lymph node metastases usually low in the neck, and in any situation in which there are multiple bilateral lymph node enlargements, particularly in young adults, the possibility of papillary thyroid cancer must be considered. More commonly however, such bilateral or multiple lower cervical masses result from sarcoidosis, lymphosarcoma, or metastases from other thoracic or abdominal viscera. Lesions such as multiple parathyroid adenomas are rarely palpable and need. not be considered in such a scheme. Upper cervical bilateral masses may also be noted in lymphosarcoma, occasionally in sarcoidosis, and, in children at least, in viral and inflammatory conditions. Lesions of the parotid gland are occasionally bilateral, such as Warthin's tumor, mixed tumors, and benign enlargement of the parotid gland. Parotid enlargement may occur spontaneously or as a part of Sjogren's syndrome or Mikulicz's disease. In addition, of course, the diagnosis of mumps must be considered in bilateral parotid masses, particularly in children but on occasion also in adults. Other causes of bilateral parotid and salivary gland enlargement may include hepatic cirrhosis, sarcomatous or leukemic infiltration of the glands, or sarcoidosis. It is not uncommon for epidermoid carcinomas of the base of the tongue, pharyngeal wall, or nasopharynx to metastasize simultaneously to both upper jugular chains. At the time when a patient is seen because of cervical masses, these relatively occult cancers frequently may have few or no symptoms related to the primary location. Of course, lymphosarcoma and Hodgkin's disease also frequently present V\'ith bilateral jugular lymph node masses frequently involving the entire jugular chain. In elderly patients, chronic lymphocytic leukemia on occasion will present with diffuse lymphadenopathy and should be considered. Posterior cervical lymph node enlargements may be caused by rubella or pediculosis capitis. Solitary cervical masses in the midline can be essentially related to the embryologic pathway of the thyroid gland and consist almost exclusively of thyroglossal duct cysts and pyramidal lobes of the thyroid that overlie the upper part of the trachea and lower part of the larynx. Pyrami-
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dallobes of the thyroid are seldom enlarged in the absence of generalized thyroid enlargement. Additionally, pretracheal and prelaryngeallymph nodes are occasionally enlarged, most noteworthy being the Delphian node, which sometimes displays early metastases from a malignant lesion of the thyroid gland. Submental lymph nodes are seldom palpated as a solitary mass and usually are somewhat lateral. Submental dermoid cysts occur, but are usually slightly off the midline. Occasionally, thyroglossal cysts may occur far enough from the midline of the neck to make the diagnosis obscure. Lateral, solitary, cervical masses constitute the majority of surgical lesions in the neck area and may be described from above downward. Thus, the usual parotid mass appears directly behind the angle of the jaw just below the lobe of the ear. Frequently these are quite subtle in presentation with a mere alteration in the slight depression behind the mandibular angle in early stages. Upper jugular lymph nodes may occur somewhat above and behind this point, in which location they frequently reflect metastatic disease originating in the nasopharynx, tonsillar fossa, or external auditory canal. Upper jugular lymph nodes may also appear slightly below the angle of the jaw, where they are commonly called subdigastric nodes. In this location, solitary cervical masses frequently herald metastasis from a lesion in the base of the tongue, posterior floor of the mouth, or retromolar triangle area Slightly lower in the neck, solitary lateral cervical masses may represent a branchial cleft cyst, which tends to lie along the anterior border of the sternocleidomastoid muscle. Other lesions in the midcervical area would include neurogenic tumors and carotid body tumors. Low in the neck, solitary lesions most likely represent thyroid masses, isolated metastases from lesions in the thoracic or abdominal cavities, or cervical metastases from a neoplasm of the thyroid. Solitary jugular masses may also arise from metastases from cutaneous lesions of the head such as melanoma or squamous cell carcinoma. Occult primary sites in the hair-bearing area should be examined in order not to overlook such a lesion. Of course, the entire skin of the head and neck should be inspected for the presence of such cutaneous lesions, since melanomas of this area are not uncommon.
SUMMARY Masses in the neck area should be evaluated by thorough historical investigation as well as by meticulous physical examination of both the lesion and the remainder of the neck and the head. By diligence in these examinations, a presumptive diagnosis can usually be attained. Biopsy of neck masses should be considered only after such a complete physical examination which should include oral cavity and laryngeal examination. Every consideration should be given to the use of needle aspiration biopsy as a preliminary office procedure. If appropriately interpreted, the smears from such a biopsy can frequently produce an accurate histologic diagnosis and thus enable proper organization of therapy. Consideration of the many differential diagnostic points related to the physical examination of neck masses has been given.
Tissue masses in the neck are a common presentation of disease as seen in the surgeon's office. An easily remembered scheme for rapid clinical evaluation of these masses is helpful in planning diagnostic procedures, considering therapeutic steps, and advising patients as to preliminary diagnosis and prognosis. For simplicity, neck masses may be thought of as unilateral or bilateral, multiple or solitary, and upper or lower. In addition, solitary masses must be categorized as midline or lateral. The surgeon must have several options in mind regarding the neck mass, and several questions must be asked. Is this mass likely to be benign or malignant? If benign, is surgical therapy necessary? If malignant, is this a generalized or regional process? If this is a regional malignant process, should the basic therapy be surgical or nonsurgical? If the therapy is to be surgical, will preliminary histologic diagnosis of the neck mass be necessary? Direct, open surgical biopsy of a neck mass should never be considered until the surgeon has analyzed the mass in relation to such a scheme. Direct surgical biopsy should be performed only if the likelihood of benignancy is extremely high or, if malignancy is considered, the surgeon is prepared to deal with all surgical eventualities at the time of operation, after obtaining a frozen section. Casual biopsy without frozen section and without thorough clinical evaluation and application of critical reasoning is only to be condemned, since valuable surgical dissection planes may be destroyed or, worse, seeded with cancer cells, which may drastically alter recurrence rates and curability. Strong consideration should be given to the use of needle aspiration biopsy of neck masses that are considered potentially malignant when tissue diagnosis is necessary before deciding to operate. Most pathologists familiar with cytology and techniques of the Papanicolaou smear are willing to give reasonably accurate diagnoses on the basis of an aspiration smear from a mass in the neck, for example, lymphosarcoma, epidermoid carcinoma, or carcinoma of the thyroid. More detailed histologic diagnoses may not be obtained, but this much information can provide valuable guidelines as to future surgical management. Thus, the neck mass Surgical Clinics of North America- Vol. 50, No. 3, June, 1970
559
560
BLAKE CADY
may be approached directly by radical neck dissection if the biopsy specimen indicates epidermoid carcinoma from the oral cavity or larynx, or it may be approached directly for open surgical biopsy for an accurate description of the particular type of lymphosarcoma after preliminary estimation that it is not an epithelial tumor. In addition, a smear of a carcinomatous node from the thyroid gland is distinctive enough that the surgeon may have valuable preliminary knowledge and may plan appropriate surgical incisions and dissections. First consideration in the evaluation of neck masses should be given to a careful, detailed history. Age, of course, is a good indication of disease, since infants with neck masses have a high frequency of benign or congenital lesions, such as cystic hygromas and occasionally bronchogenic cysts and thyroglossal duct cysts, while young adolescents are likely to have lymphadenopathy on the basis of inflammatory or viral diseases. Teenagers and young adults with neck masses should always be suspected of having lymphosarcoma or carcinoma of the thyroid. Elderly patients are more likely to have epidermoid carcinoma arising in the upper part of the respiratory system or oral cavity and are more likely to display metastatic disease from viscera, such as the lung, stomach, or pancreas. Rapidity of enlargement of a mass, possible fluctuations in size, pain, tenderness, and constitutional symptoms are diagnostic clues. Branchial cleft cysts, thyroglossal duct cysts, and preauricular cysts frequently display fluctuations in size, sometimes with apparent drainage of material onto the skin. Warthin's tumor of the parotid gland frequently has a clear history of size fluctuations consistent with the large amount of lymphoid tissue. Salivary glands with episodes of ductal obstruction usually have a history of more rapid fluctuations in size related to eating. Such size fluctuations may occur with great rapidity, and it is not uncommon for patients with branchial cleft cysts or thyroglossal duct cysts to relate the almost overnight appearance of a mass associated with a respiratory tract infection. Surprisingly, patients with known malignant conditions will relate relatively rapid enlargement of a mass in the neck, when it is apparent that the disease has been present for a considerable period. It should be understood that a mass in the neck that may have been present for some time frequently produces the history of sudden appearance and rapid increase in size and is eventually proved to be metastatic carcinoma. Of course, tenderness is usually associated with inflammatory processes but may herald an acute obstructive phenomenon such as obstruction of a submaxillary duct by calculus or sudden duct obstruction in a thyroglossal cyst. Constitutional reactions are of particular concern in the history because of clues offered in diagnosis. Fatigue, malaise, anorexia, and weight loss most likely indicate generalized disease, whether viral, inflammatory or neoplastic. Constitutional symptoms may indicate an advanced malignant lesion such as carcinoma of the lung or gastric carcinoma with metastases. Neck masses appearing in the presence of constitutional symptoms indicate nonsurgical disease. Thus, the surgical masses that appear in the neck, such as thyroid metastases, epidermoid
EvALUATION OF NECK MASSES
561
cancer metastases, parotid tumors, or benign lesions usually have no constitutional symptoms. Specific complaints referable to the upper part of the respiratory tract or to the digestive system may give clues as to involvement by primary cancer. Thus, all patients should be questioned specifically for the possibility of hoarseness, sores in the mouth, dysphagia, cough, hemoptysis, nasal obstruction, episodes of ear infections, and so forth. All these may offer clues as to malignant lesions in the nasal, oral, pharyngeal, or laryngeal regions. Other aspects of specific interest in the history should include a detailed investigation of smoking habits. It is well known that heavy pipe and cigar smokers have a considerable incidence of oral cavity and pharyngeal epidermoid cancer, while the risk is also present in heavy cigarette smokers. Those patients who chew tobacco or use a quid of snuff habitually eventually undertake considerable risk of carcinoma of the buccal mucosa or oral cavity. Histories of exposure to radiation or to animals and occupational and health histories should be taken, with particular concem to any recent manipulations in the upper oral or respiratory tract cavities such as dental extractions. Radiation therapy even in low doses has been heavily implicated in the development of carcinoma of the thyroid in young adults and should always be investigated in potential thyroid masses. Patients with unusual inflammatory conditions such as cat-scratch fever may occasionally present with cervical adenitis, as may those with certain fungal infections and nonspecific conditions such as sarcoid. This abbreviated outline points out the necessity of taking a detailed history in patients seen with neck masses. The surgeon should be skilled in use of the laryngeal mirror for vocal cord and laryngeal examination as well as for surveys of the nasopharynx. No biopsy of a neck mass that is of indeterminate cause should be undertaken without accurate examination of the larynx, base of tongue, tonsillar fossa, pharyngeal wall, and nasopharynx. Furthermore, accurate and detailed assessment of the oral cavity should be performed by palpation as well as by visual inspection. This necessitates the removal of dentures and the use of a finger cot or a plastic glove to enable every accessible part of the mouth to be seen and touched. The base of the tongue can be inspected by palpation at the conclusion of examination of the oral cavity by sweeping the index finger over its surface after carefully cautioning the patient of the possible sensation of gagging. Bimanual palpation of the cheeks, floor of the mouth, and gingival buccal sulci is also essential in evaluating these areas, particularly for masses occurring in the submaxillary and submental spaces. This aspect of the physical examination is one of the most neglected, based on lack of familiarity with the anatomy and infrequency of the disease. These examinations should be utilized frequently enough on normal patients so that, when necessary, confidence in assessing the findings in the upper digestive and respiratory areas will be adequate. With the patient seated, both sides of the neck should be examined, and the patient should be instructed to turn the head from side to side and to swallow to visual-
562
BLAKE CADY
ize the masses more fully. Palpation should be performed beginning with the jugular chain of lymph nodes from the mastoid process and upper part of the neck to the lower part of the neck and including the other regions of lymphatic tissue, such as the chain of nodes accompanying the spinal accessory nerve and in the supraclavicular fossa lateral to the lower part of the sternocleidomastoid muscle. This can be accomplished most easily by holding the patient's head with the opposite hand and rotating the head slightly to the side opposite the mass to release tension on the sternocleidomastoid muscle. The side of the neck should be palpated both with the flat of the hand and by picking up the sternocleidomastoid muscle between the thumb and fingers to evaluate the tissue beneath and adjacent to the sternocleidomastoid muscle and jugular vein. In addition, with the head tilted toward the side being examined, tension on the supraclavicular fossa and trapezius muscles can be eased so that these regions can be palpated carefully and completely. The course of the carotid vessels should be outlined on each side so that the relation of the masses to the carotid bulb can be determined. The area of the submaxillary and submental spaces is less easily assessed than the jugular region; the physician must examine these spaces bimanually with one finger inserted into the oral cavity. The thyroid area should be inspected in detail by relaxing the adjacent muscles as described and palpating over and around the lower portion of the sternocleidomastoid muscle and adjacent to the upper part of the trachea and lower part of the larynx. Careful palpation directly over the trachea should indicate the location of the thyroid isthmus and offer clues as to the relative size and location of the thyroid gland. Examination of the thyroid can also be performed from behind, frequently offering more subtle evaluation of the thyroid lobes with the flats of the fingers over the lower anterior portion of the neck. Examination of the thyroid should be performed with the patient swallowing or sipping from a glass of water. Masses in the upper midline of the neck should also be assessed in relation to swallowing, as cysts of the thyroglossal duct frequently move in conjunction with the base of the tongue and hyoid bone. Detailed physical examination of the neck masses must be performed, with particular attention to location, consistency, movability, tenderness, size, and configuration. As previously mentioned, the masses must be examined with consideration of the location in either the upper or lower part of the neck, whether they are multiple or solitary, and, if solitary, whether they are midline or lateral. In addition, location in relation to skin should be noted. Are these lesions within or attached to the skin, such as sebaceous cysts, or are they in the subcutaneous fat, such as lipoma? In judging consistency, the physician should estimate masses in regard to a rather poorly defined descriptive terminology: cystic, implying the sensation of fluid under pressure; fluctuant, suggesting fluid not under pressure; inflammatory, indicating a soft and pliable sensation such as might be noted with slightly enlarged but relatively normal lymph nodes; fleshy, as in lymph nodes that are enlarged with the capsule stretched over slightly compressed tissue, giving the sensation of a soft, gum rubber eraser; and hard, giving the impression of distinct firmness not associated with normal tissue.
EVALUATION OF NECK MASSES
563
In particular, branchial cleft cysts and thyroglossal duct cysts tend to have expected cystic qualities. Abscessed lymph nodes with purulent contents may produce a sensation of fluctuation. Enlarged submaxillary salivary glands usually feel soft and fatty with a somewhat irregular, slightly lobulated surface. However, if the submaxillary salivary gland has been chronically enlarged because of a partially obstructed duct, it frequently is the site of chronic inflammatory changes with fibrosis and feels much firmer and on occasion even hard. In the evaluation of patients with epidermoid carcinoma of the oral cavity, such an enlarged gland sometimes cannot be distinguished from a lymph node involved with metastatic cancer. Infectious lymphadenopathy tends to feel soft and fleshy also, but nevertheless has a slightly firmer sensation than that of a normal submaxillary salivary gland. Cervical lymph nodes enlarged as a result of lymphosarcoma tend to have a certain rubbery firmness. In addition, of course, mixed tumors of the parotid gland frequently feel rubbery~ as if the tissue contained within the capsule were under tension . This characteristic is borne out when hemisections of sarcomatous lymph nodes or mixed tumors of the parotid gland are performed; the cut surface of these lesions bulges because of the increased pressure of tissue within the capsule or pseudocapsule. Other parotid lesions may feel either inflammatory, such as Warthin's tumor, which is composed largely of lymphoid tissue, or hard, such as parotid carcinoma, which frequently has the characteristic hardness of an epithelial malignant lesion. It should also be noted that metastatic papillary carcinoma of the thyroid in cervical lymph nodes frequently has the sensation of a soft, fleshy, inflammatory lymph node and is not suspected clinically to be malignant. Finally, a lymph node involved with metastatic epidermoid carcinoma from the upper respiratory or digestive passages has a characteristic hard sensation and, in addition, is frequently fixed to the surrounding structures because of growth through the lymph node capsule and into surrounding tissues. Some neck masses have a bony hardness on palpation and are, in fact, related to relatively normal anatomic structures in the neck. One common bony mass palpated in the upper part of the neck is the transverse process of the second cervical vertebra, which is occasionally prominent just below the mastoid process. If the patient has recently lost weight and the amount of subcutaneous tissue has decreased, this bony mass may easily be felt either by the patient or by the physician. Not only are such bony.masses of a distinctive consistency but they are also naturally completely immobile. On occasion, cervical ribs may be palpated in the middle portion of the neck, and these are distinguished by bony hardness and fixation. The greater cornu of the hyoid bone is hard but fairly movable. Any lymph node more than 2 em. in diameter is most likely to contain a malignant growth. Exceptions to this rule are found in sarcoidosis and in some of the more unusual inflammatory lesions, such as catscratch fever and tubercular adenopathy. The movability of neck masses is of some consequence in differential diagnosis, and during physical examination definite attempts should be made to move these masses in at least two different planes.
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Much information can be gained by this. For instance, neuromas of the vagus nerve and carotid body tumors frequently. can be moved in a horizontal plane but are relatively immovable in a vertical plane. This also might apply to branchial cleft cysts and thyroglossal duct cysts because of the embryonic remnants that tend to fix them in a vertical plane but allow motion in the horizontal plane. Movability, of course, is also related to fixation to surrounding structures that most commonly occurs with inflammatory reactions about the nodes or neoplastic involvement of the tissues surrounding lymph nodes. Movement in relation to swallowing is characteristic of the thyroid gland, and upward movement on protrusion of the tongue is a unique feature of thyroglossal duct cysts. Tenderness most frequently is related to inflammatory changes in neck masses; however, it can also be related to episodes of sudden obstruction even without inflammatory changes, such as an acutely obstructed submaxillary salivary gland duct or an acutely distended branchial cleft cyst. Acute thyroiditis may present as a tender mass in one or both lobes of the gland low in the neck. Masses of nodes in the low jugular chain or in the area near the lymphatic-venous junction will present as fixed masses when involved by metastatic carcinoma originating in the lung, esophagus, or abdominal cavity. Infrequently, advanced breast cancer metastatic to supraclavicular lymph nodes will present as fixed masses in this region. In the upper part of the neck, fixed masses are usually associated with metastatic carcinoma arising in the nasopharyngeal or oral area. The question of fixation of masses is important in evaluating patients for suitability for operation, since the presence of a densely fixed mass in the jugular chain indicates that the lesion is of borderline operability at best and probably is inoperable. The size of the lesion is important, as previously mentioned. However, it should be recognized that multiple small nodes in the neck can indicate metastatic papillary carcinoma of the thyroid or early lymphosarcoma as well as generalized inflammatory lesions of lymph nodes, such as infectious mononucleosis or childhood viral illnesses. The configuration of the mass in the neck, of course, is also important, since lesions that stretch an encompassing capsule tend to assume a rounded configuration, while lesions that develop within a tubular or elongated structure tend to have a linear configuration in part. Thus, branchial cleft cysts and thyroglossal duct cysts frequently give the sensation of tails running off at upper and lower ends of the cyst, indicating attachment to embryologic structures. In addition, neurogenic tumors in the neck frequently have an elongated configuration, indicating origin in a vertical, elongated structure. Enlarged salivary glands tend to have a more irregular over-all configuration than abnormalities of lymph nodes, for instance. In addition, the sensation of a carotid body tumor may be distinctly different, not only because of its adherence to a pulsating structure and its relative fixation vertically but also because of its configuration, which may be more flattened and disc-like than globular. The careful palpation of a pulsatile mass in the neck in older patients frequently will reveal that what was originally thought to be a carotid
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aneurysm is a tortuous carotid vessel that has kinked or sometimes nearly twisted upon itself. Frequently the rigid calcific walls of an arteriosclerotic carotid vessel, particularly at the bifurcation of the common carotid artery, may be misinterpreted on hasty examination. A Y-shaped configuration and the sensation of a hard mass that is movable laterally may confirm the fact that this is an arteriosclerotic plaque, which may not have a readily palpable pulse if the vessel is nearly occluded. In the evaluation of specific masses discovered within the neck on physical examination, illustrations of some of the diagnostic points previously mentioned will be helpful. Lesions that have the least likelihood of being surgical in nature are those that are bilateral and lower in the neck. The principal surgical lesions to consider in this area are thyroid masses with or without jugular lymph node enlargement. Adenomatous goiter or chronic thyroiditis may present as masses in both lobes of the thyroid gland and as such, of course, is unlikely to be accompanied by lymph node masses. However, papillary carcinoma of the thyroid that might arise in one lobe frequently has bilateral lymph node metastases usually low in the neck, and in any situation in which there are multiple bilateral lymph node enlargements, particularly in young adults, the possibility of papillary thyroid cancer must be considered. More commonly however, such bilateral or multiple lower cervical masses result from sarcoidosis, lymphosarcoma, or metastases from other thoracic or abdominal viscera. Lesions such as multiple parathyroid adenomas are rarely palpable and need. not be considered in such a scheme. Upper cervical bilateral masses may also be noted in lymphosarcoma, occasionally in sarcoidosis, and, in children at least, in viral and inflammatory conditions. Lesions of the parotid gland are occasionally bilateral, such as Warthin's tumor, mixed tumors, and benign enlargement of the parotid gland. Parotid enlargement may occur spontaneously or as a part of Sjogren's syndrome or Mikulicz's disease. In addition, of course, the diagnosis of mumps must be considered in bilateral parotid masses, particularly in children but on occasion also in adults. Other causes of bilateral parotid and salivary gland enlargement may include hepatic cirrhosis, sarcomatous or leukemic infiltration of the glands, or sarcoidosis. It is not uncommon for epidermoid carcinomas of the base of the tongue, pharyngeal wall, or nasopharynx to metastasize simultaneously to both upper jugular chains. At the time when a patient is seen because of cervical masses, these relatively occult cancers frequently may have few or no symptoms related to the primary location. Of course, lymphosarcoma and Hodgkin's disease also frequently present V\'ith bilateral jugular lymph node masses frequently involving the entire jugular chain. In elderly patients, chronic lymphocytic leukemia on occasion will present with diffuse lymphadenopathy and should be considered. Posterior cervical lymph node enlargements may be caused by rubella or pediculosis capitis. Solitary cervical masses in the midline can be essentially related to the embryologic pathway of the thyroid gland and consist almost exclusively of thyroglossal duct cysts and pyramidal lobes of the thyroid that overlie the upper part of the trachea and lower part of the larynx. Pyrami-
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dallobes of the thyroid are seldom enlarged in the absence of generalized thyroid enlargement. Additionally, pretracheal and prelaryngeallymph nodes are occasionally enlarged, most noteworthy being the Delphian node, which sometimes displays early metastases from a malignant lesion of the thyroid gland. Submental lymph nodes are seldom palpated as a solitary mass and usually are somewhat lateral. Submental dermoid cysts occur, but are usually slightly off the midline. Occasionally, thyroglossal cysts may occur far enough from the midline of the neck to make the diagnosis obscure. Lateral, solitary, cervical masses constitute the majority of surgical lesions in the neck area and may be described from above downward. Thus, the usual parotid mass appears directly behind the angle of the jaw just below the lobe of the ear. Frequently these are quite subtle in presentation with a mere alteration in the slight depression behind the mandibular angle in early stages. Upper jugular lymph nodes may occur somewhat above and behind this point, in which location they frequently reflect metastatic disease originating in the nasopharynx, tonsillar fossa, or external auditory canal. Upper jugular lymph nodes may also appear slightly below the angle of the jaw, where they are commonly called subdigastric nodes. In this location, solitary cervical masses frequently herald metastasis from a lesion in the base of the tongue, posterior floor of the mouth, or retromolar triangle area Slightly lower in the neck, solitary lateral cervical masses may represent a branchial cleft cyst, which tends to lie along the anterior border of the sternocleidomastoid muscle. Other lesions in the midcervical area would include neurogenic tumors and carotid body tumors. Low in the neck, solitary lesions most likely represent thyroid masses, isolated metastases from lesions in the thoracic or abdominal cavities, or cervical metastases from a neoplasm of the thyroid. Solitary jugular masses may also arise from metastases from cutaneous lesions of the head such as melanoma or squamous cell carcinoma. Occult primary sites in the hair-bearing area should be examined in order not to overlook such a lesion. Of course, the entire skin of the head and neck should be inspected for the presence of such cutaneous lesions, since melanomas of this area are not uncommon.
SUMMARY Masses in the neck area should be evaluated by thorough historical investigation as well as by meticulous physical examination of both the lesion and the remainder of the neck and the head. By diligence in these examinations, a presumptive diagnosis can usually be attained. Biopsy of neck masses should be considered only after such a complete physical examination which should include oral cavity and laryngeal examination. Every consideration should be given to the use of needle aspiration biopsy as a preliminary office procedure. If appropriately interpreted, the smears from such a biopsy can frequently produce an accurate histologic diagnosis and thus enable proper organization of therapy. Consideration of the many differential diagnostic points related to the physical examination of neck masses has been given.