Step 2 CK · Ophthalmology & ENT

Neck Masses & Salivary Disease

Name: Neck Masses & Salivary Disease
Creator: Veli Bakalov, MD

Age and location narrow the neck-mass differential

Ophthalmology & ENT·Nose, Mouth, Throat & Neck·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Neck mass by age: children and young adults = congenital or inflammatory; adult over 40 with a firm, persistent mass = metastatic squamous cell carcinoma until proven otherwise.
Worrisome nodes are firm, fixed, painless, over 2 cm, persisting 2 weeks or more without regression (AAO-HNS), or supraclavicular; a left supraclavicular (Virchow) node signals abdominal or gastric cancer.
Thyroglossal duct cyst: midline mass that rises with tongue protrusion and swallowing; may be the only thyroid tissue; Sistrunk procedure (cyst + central hyoid).
Branchial cleft cyst: lateral mass at the anterior SCM border in a young adult, swelling after a URI; in adults over 40, a cystic lateral node may be HPV-related oropharyngeal SCC, so FNA it.
Thyroid nodule: serum TSH first; low TSH → radioiodine scan (hot nodules are rarely malignant); normal or high TSH → ultrasound and FNA by size and suspicious features.
FNA first for most neck masses and suspected metastatic SCC nodes (open biopsy can seed tissue); excisional biopsy only when lymphoma is suspected.
Head and neck SCC: tobacco plus alcohol act synergistically; HPV-16 drives oropharyngeal (tonsil, base of tongue) cancer in younger nonsmokers with a better prognosis; workup is FNA, imaging, and panendoscopy.
Salivary stones favor the submandibular (Wharton) duct (alkaline, calcium-rich saliva draining uphill); acute suppurative parotitis in dehydrated elderly or post-op patients is Staphylococcus aureus.
Salivary tumors: parotid tumors are mostly benign (pleomorphic adenoma most common, Warthin second in older male smokers); smaller glands are more often malignant; mucoepidermoid is the most common malignancy and adenoid cystic invades nerves.

Approach: age, location, and node character

Age comes first. In children and young adults, most neck masses are congenital or inflammatory (reactive lymphadenopathy). In an adult over 40, a firm, persistent neck mass is metastatic squamous cell carcinoma until proven otherwise. Location narrows the list further: midline masses suggest a thyroglossal duct cyst or the thyroid, and lateral masses suggest a branchial cleft cyst or lymph nodes.

Reactive versus worrisome lymph nodes

Feature	Reactive	Worrisome
Feel	Tender, mobile, small	Firm, fixed, painless, over 2 cm
Time course	Transient, with an infection	Persisting 2 weeks or more without regression
Location	Anterior cervical, draining an infection	Supraclavicular node at any size
Systemic clues	URI or pharyngitis	B symptoms (fever, night sweats, weight loss) suggest lymphoma

A left supraclavicular (Virchow) node drains the abdomen and classically signals gastric or other GI malignancy; a right supraclavicular node points to the chest (lung, esophagus).

Congenital neck masses

Thyroglossal duct cyst. A midline mass that rises with tongue protrusion and swallowing, from a persistent tract between the foramen cecum and the thyroid. It may contain the only functioning thyroid tissue, so confirm a normally located thyroid on ultrasound before surgery. Treat with the Sistrunk procedure: excise the cyst, the tract, and the central portion of the hyoid.

Branchial cleft cyst. A smooth lateral mass along the anterior border of the sternocleidomastoid in a child or young adult, often enlarging after a URI.

Congenital neck masses

Lesion	Location	Clue	Treatment
Thyroglossal duct cyst	Midline	Elevates with tongue protrusion	Sistrunk procedure
Branchial cleft cyst	Lateral, anterior to the SCM	Swells after a URI	Excision once infection settles
Cystic hygroma (lymphatic malformation)	Posterior triangle	Soft, transilluminates; associated with Turner syndrome	Excision or sclerotherapy
Dermoid cyst	Midline	Does not move with the tongue	Excision

In an adult over 40, a new cystic lateral node can be a metastasis from HPV-related oropharyngeal carcinoma masquerading as a branchial cyst. Evaluate with FNA rather than assuming it is benign.

Thyroid nodules

Serum TSH firstIt decides the next test.
Low TSHRadioiodine uptake scan: a hot (hyperfunctioning) nodule is rarely malignant and needs no FNA.
Normal or high TSHThyroid ultrasound.
FNAChosen by size and suspicious features: microcalcifications, hypoechogenicity, irregular margins, taller-than-wide shape.

Thyroid nodule workup

FNA is the key test for malignancy. With a normal or high TSH, the next step is ultrasound with FNA of qualifying nodules, not a radioiodine scan, radioiodine ablation, or empiric thyroidectomy. Most thyroid nodules are benign.

Biopsy strategy and head and neck cancer

FNA first, excise for lymphoma. FNA is first-line for most neck masses, thyroid nodules, and suspected metastatic SCC nodes. An up-front open biopsy of a metastatic node can seed tissue planes and worsen outcomes. The exception is suspected lymphoma, where excisional biopsy is needed because diagnosis depends on nodal architecture.

Head and neck squamous cell carcinoma. Classically caused by combined tobacco and alcohol use, which act synergistically to multiply risk. It presents as a nonhealing ulcer, hoarseness, dysphagia, or a metastatic neck node. Erythroplakia and leukoplakia are premalignant oral lesions, with erythroplakia carrying the higher risk.

HPV-related cancer. HPV-16-associated SCC arises in the oropharynx (tonsil, base of tongue), affects younger nonsmokers, is rising in incidence, and carries a better prognosis; p16 staining serves as its marker. It often presents as a cystic level II neck node that mimics a branchial cleft cyst.

Examine the mucosaFull head and neck exam, including the oral cavity and oropharynx.
ImageContrast CT (or ultrasound) of the neck.
FNAOf the mass or node; not an open excisional biopsy.
ENT referral and panendoscopyWhen malignancy is suspected, to find the primary and any synchronous second primary.

Persistent adult neck mass

Antibiotics are appropriate only when an inflammatory cause is likely, and a trial of antibiotics should never delay the cancer workup in an older smoker.

Salivary gland disease

Sialolithiasis. Recurrent pain and swelling of a gland with meals. Most stones lodge in the submandibular (Wharton) duct, because its saliva is alkaline and calcium-rich and the duct drains uphill. Manage with hydration, sialagogues (sour candy), massage, and stone removal.

Acute suppurative sialadenitis. A painful, swollen, warm gland, usually the parotid, with pus expressed from the duct, in a dehydrated, elderly, or post-operative patient. Staphylococcus aureus is the usual organism. Treat with hydration, sialagogues, and antistaphylococcal antibiotics.

Bilateral parotid swelling in an unvaccinated patient suggests mumps (viral parotitis), which can also cause orchitis, pancreatitis, and meningitis.

Salivary gland tumors

Tumor	Behavior	Clues
Pleomorphic adenoma	Benign; most common salivary tumor	Painless, slow-growing, mobile parotid mass; recurs if simply enucleated, so superficial parotidectomy sparing CN VII
Warthin tumor	Benign; second most common	Bilateral in some; older male smokers
Mucoepidermoid carcinoma	Most common malignant	Pain or facial nerve palsy
Adenoid cystic carcinoma	Malignant	Perineural invasion

Big gland, benign; small gland, bad: most tumors arise in the parotid and are benign, while submandibular and minor salivary tumors carry a higher malignancy risk.

Facial nerve weakness or pain in a salivary mass signals malignancy.