Non-nodal masses

Thyroid masses

The thyroid gland sits in the anterior neck (like a bow tie) overlying the trachea. It is adherent to the trachea by the pretracheal fascia; this is a condensation of the connective tissue in the neck overlying the windpipe. As a result, thyroid masses characteristically move on swallowing - as the larynx and trachea move up and down, so too does the thyroid gland. Thyroid masses are common in adults but rare in children. They are best assessed radiologically with an ultrasound scan and FNA to obtain a tissue sample to identify the nature of the lump. Further details of thyroid masses and disease can be found in Chapter 36.

Salivary masses

Parotid masses can be located in the main body of the gland or in the tail - this is the portion of the gland that is posterior and inferior to the angle of the mandible. Submandibular and parotid tail masses can be primary salivary lesions or lymph nodes, hence careful clinical examination alongside ultrasound and FNA will help to differentiate between the two. Further details of salivary masses and disease can be found in Chapter 35.

Cystic neck masses

Children and young adults may present with a cystic swelling in the middle of the neck. Patients may simply notice the lump, or may attend because of infection in the cyst. Clinically, these lumps move when the patient swallows and on sticking out their tongue and are likely to be a thyroglossal duct cyst. The thyro-glossal duct is the tract along which the thyroid gland descends during embryonic development which fails to obliterate (see Chapter 36). Treatment for this is surgical excision including the central portion of the hyoid bone - known as Sistrunk’s procedure. Removal of the bone lessens the chance of recurrence of the cyst after surgery.

Branchial cysts are lateral neck swellings usually seen in young adults arising anterior to the upper third of the sternocleidomastoid muscle. Patients present after noticing the mass or because of acute swelling often caused by infection within the mass. The cysts are thought to be due to degeneration within lymph nodes. Clinically, they are firm swellings in the upper neck, which are easy to palpate the front but difficult to feel the posterior extent clearly. FNA will aspirate cloudy cyst contents which may contain cholesterol crystals. Treatment is surgical removal.

In patients over 40 years cystic lumps that clinically resemble branchial cyst should be viewed with suspicion, as metastatic head and neck cancer can present with cystic neck nodes. These should not be removed, but referred on for a specialist head and neck surgical opinion.

Vascular masses

Vascular neck masses are uncommon and are usually related to the carotid artery. These may take the form of abnormal dilatations of the carotid artery (an aneurysm) or a normal but tortuous artery. The carotid bulb (the point at which the internal carotid originates from the common carotid) may be enlarged but normal - this may be mistaken for a vascular mass. Furthermore, a normal lymph node overlying the carotid bifurcation can resemble a vascular lesion. True vascular masses develop at the bifurcation of the common carotid and are called carotid body tumours. These are benign lesions that arise from chemoreceptors in the carotid bulb and present as painless lumps. These are investigated with ultrasound and MRI scans; FNA is generally avoided in these masses. Treatment is by embolisation of the feeding vessels and surgical excision.

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