Ear, Nose and Throat - U.S.A.  (ENT USA) Benign Neck Masses
Neck Masses
Neck Masses
  
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A lump or mass in the neck can be from many causes.  The neck normally has lumps and many normal structures can cause patients to worry they have cancer and other types of diseases.  Four normal structures which are commonly confused for a neck mass are as follows:  (Note:  A physician is often required to accurately identify these structures.)
 
  • The Transverse Process of the Second Cervical Vertebrae:  This process can form a hard mass located between the tip of the mastoid process and the angle of the mandible.  It is hard, solid and fixed.  Lymph nodes and tumors in the tail of the parotid may mimic this mass.  (Most parotid tumors can be brought up over the mandible since they are located above or lateral to the superficial cervical fascia.)  Often the transverse process has a similar examination on both sides.  If this is the case it is a clue that one is dealing with a normal structure. 
     
  • The Carotid Bulb:  This structure is located below the angle of the mandible.  The key physical finding is that this mass pulsates, however, so will a small mass over the bulb as well as a carotid body tumor.
     
  • The Hyoid Bone:  The greater horn of the hyoid bone will sometimes produce a mass effect between the carotid bulb and angle of the mandible.  The key physical finding that the opposite side almost always has a similar mass.  Since the hyoid bone is a "C" shaped structure, grabbing the two prominences at once, one can move the one side medially and the other will move laterally. 
     
  • The Submaxillary (Submandibular) Gland:  The submaxillary gland is a large salivary gland located below the mandible.  As one ages it drops down and can be easily felt along with causing concern.  The gland is soft usually the same on both sides.  Bimanual palpation (one hand in the floor of the mouth and the other on the neck) can express saliva with palpation and usually allow accurate identification. 

 


Shown in the pictures above are the CT scan and surgical specimen of a branchial cleft cyst in a 12 year old male.  This is a congenital cyst which is treated with surgical removal

     

 

Young children often have lymph nodes in their upper neck and cause concern to the parents.  These may be caused from tonsillar infections.  Hallmarks of a benign (non-cancerous) process are that the mass is bilateral (both sides), soft, mobile and is not increasing in size.  Over 90% of children have lymph nodes in this area and not all can be biopsied.   However, if they become hard, fixed and multiple, biopsy to rule out a cancer may be necessary. 

In adults, neck masses are commonly caused by an infection, such as chronic tonsillitis or an infected tooth.  Other causes include congenital cysts (sacs of fluid) and cancers.  An exact diagnosis may be difficult without a biopsy. 

Masses in the posterior neck are often lymph nodes along the spinal accessory nerve.  Open biopsy in this area must be done with extreme caution because of risk to injuring this nerve and paralyzing the trapezius muscle.  This is a large muscle which raises the arm above the shoulder.

Masses in the lower neck are very worrisome, especially if just off midline.  A mass in this area may represent lymph nodes involved with cancer which has metastasis from the lungs or abdomen.  This is a common presentation of lung cancer. 

Masses are worrisome when they persist, are multiple, or are hard and fixed.  Because taking a large sample of tissue from the neck requires surgery, your doctor may decide to do a "needle biopsy".  A needle biopsy is performed by inserting a fine needle into the mass and using negative pressure to obtain a few cells for the pathologist to look at.  Unfortunately, this procedure is only about 95% accurate. 

An open biopsy, as shown below, is much more accurate, but it is difficult to do and may put various important structures at risk.

In the patient shown below, a needle biopsy indicated that the neck mass was from a congenital cyst.  However, upon exploration, infected lymph nodes were found.

neck_operation.jpg (66190 bytes)

View of a Neck Exploration
Mouse-over picture to identify
structures, click on picture to enlarge:

 

  • Diagastric Muscle

  • Sternocleidomastoid Muscle

  • Hypoglossal Nerve (Controls the Tongue)

  • Vagus Nerve (Controls the Voice Box)

  • Spinal Accessory Nerve (Controls a large Shoulder Muscle)

  • Carotid Artery (Supplies Blood to the Brain)

  • Internal Jugular Vein (Drains Blood From the Head and Brain)

 

  
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