A persistent neck mass in an adult older than 40 years is concerning for malignancy. Computed tomography of the neck with contrast and ultrasound are both good initial imaging modalities for neck masses. Ultrasound is the ideal imaging study for a thyroid lesion.
A list of things to think about (does not include all cases of masses):
- Thyroglossal duct cyst – most common congenital anomaly of the neck. Most commonly is a midline cystic mass, inferior to the hyoid bone and elevates with protrusion of the tongue. Usually found in the pediatric age group. Treat acutely infected thyroglossal cyst with antibiotics. Excision is the definitive therapy.
- Branchial cleft cyst – the 1st branchial cleft cyst is found at the mandibular angle inferior to the ear lobe and the 2nd branchial cleft cyst (most common) is located more inferior on the lateral neck. These are commonly found in late childhood to early adulthood. Treatment is the same as thyroglossal duct cysts.
- Dermoid/epidermoid cysts – frequently midline in location, commonly located in the floor of mouth or in the suprasternal notch.
- Deep neck space infections/abscesses – often caused by an odontogenic or salivary source. Typically present with tender swelling in the neck with possible overlying erythema, induration, and local fluctuance.
- Salivary gland enlargement – sialadenitis presents with pain and swelling of the affected salivary gland. Assess for purulent discharge from the duct opening into the oral cavity for evidence of active infection. Chronic inflammation is possible due to repeat sialolithiasis and sialadenitis. Sjögren syndrome can cause increased salivary gland size. Tumors can be present and are most likely to involve the parotid gland.
- Lymphadenopathy – can be caused by virus and bacteria such as HIV, infectious mononucleosis, cytomegalovirus, toxoplasmosis, and cat scratch disease. If the lymphadenopathy persists or enlarges after treatment/time, lymph node biopsy should be arranged. Scrofula (tuberculous lymphadenitis) presents as a firm, fixed mass in the posterior cervical region. Lymphadenopathy can also be caused by cancer such as lymphoma or metastasis of head/neck cancers (ie squamous cell carcinoma and papillary carcinoma of thyroid). Gastric and pulmonary cancers will metastasize to the supraclavicular nodes. Fixed, firm, matted and nodes larger than 1.5 cm require further evaluation.
- Thyroid – enlargement can be due to toxic nodular goiter and thyroid toxicosis. Thyroid nodules are the leading cause of anterior neck compartment masses. 5% of nodules harbor a malignancy. In the same area are parathyroid cysts and neoplasms.
- Lymphangioma – most commonly posterior to the sternoclidomastoid. Cystic hygroma is the most common and typically presents in children.
Rosenberg TL, Brown JJ, Jefferson GD. Evaluating the adult patient with a neck mass. Med Clin North Am. 2010 Sep;94(5):1017-29.
Schwetschenau E, Kelley DJ. The adult neck mass. Am Fam Physician. 2002 Sep 1;66(5):831-8.
Wong KT, Lee YY, King AD, Ahuja AT. Imaging of cystic or cyst-like neck masses. Clin Radiol. 2008 Jun;63(6):613-22. Epub 2008 Mar 12.