The effective and efficient management of a patient with a neck mass in a 1-stop clinic requires a collaborative and harmonious partnership among surgeon, radiologist, and pathologist. In this article, theoretic and practical issues are addressed to optimize patient care when prescribing, planning, performing, and interpreting imaging for neck disease.
Key points
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The incidence of new cases of head and neck cancer in the United Kingdom is approximately 8100.
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In most patients presenting with neck masses, the diagnosis is benign.
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The clinical effectiveness and efficiency of separating malignant from benign not only has a significant impact for the patient but also economic benefit to health care providers.
Introduction
A patient presenting to clinic with a neck lump is a common scenario for oral and maxillofacial/head and neck surgeons. In this article, the diagnosis and management of common and important neck masses are discussed, with particular focus on the various roles of imaging. The focus is on adult neck lumps. Thyroid lumps and pediatric cervical swellings are excluded from this discussion. More emphasis is placed on the practicalities of imaging and management rather than the provision of an exhaustive list of differential diagnoses.
In our department, 900 new patients present to a designated 1-stop neck lump clinic annually. The service allows regional general medical and dental practitioners the opportunity for rapid referral of patients with neck lumps of concerning origin. Most patients attending the 1-stop clinic receive senior clinician assessment, coupled with immediate ultrasonography (US) and cytologic investigations, where indicated. By the end of the patient’s visit to the clinic, the patient receives a preliminary diagnosis and a scheduled investigative time scale. After a contemporary departmental audit, approximately 12% of these new referrals are diagnosed as malignant.
Approximately 8100 new cases of head and neck cancer are registered in England annually. Seventy-three percent of patients in the United Kingdom with head and neck cancer are referred from primary care under the urgent or 2-week referral system. In the United Kingdom, the incidence of cancer with unknown primary is 10,000, many of these present as cervical malignancy with undiagnosed primary origin.
In our clinic, most presenting neck lumps are benign, with reactive or suppurative lymphadenopathy, lipomata, and superficial and deep cervical cysts. Benign disease of the parotid tail and submandibular and sublingual glands are also common presentations. Less frequent referrals relate to variations of normal anatomy: a prominent carotid bulb or a spinous process of cervical vertebra or a cervical rib.
The radiology team has an important role in the assessment and diagnosis of neck lumps. In particular, the ability of the radiologist to identify cancer spread and accurately stage malignancy is a key and often pivotal role in influencing treatment at the multidisciplinary team meeting. This situation has reflected the advances across the field of imaging in recent times. In this article, the imaging modalities available are reviewed, highlighting their merits and hurdles of use, and, second, the common and significant neck lumps presenting to our head and neck clinic are reviewed.
Introduction
A patient presenting to clinic with a neck lump is a common scenario for oral and maxillofacial/head and neck surgeons. In this article, the diagnosis and management of common and important neck masses are discussed, with particular focus on the various roles of imaging. The focus is on adult neck lumps. Thyroid lumps and pediatric cervical swellings are excluded from this discussion. More emphasis is placed on the practicalities of imaging and management rather than the provision of an exhaustive list of differential diagnoses.
In our department, 900 new patients present to a designated 1-stop neck lump clinic annually. The service allows regional general medical and dental practitioners the opportunity for rapid referral of patients with neck lumps of concerning origin. Most patients attending the 1-stop clinic receive senior clinician assessment, coupled with immediate ultrasonography (US) and cytologic investigations, where indicated. By the end of the patient’s visit to the clinic, the patient receives a preliminary diagnosis and a scheduled investigative time scale. After a contemporary departmental audit, approximately 12% of these new referrals are diagnosed as malignant.
Approximately 8100 new cases of head and neck cancer are registered in England annually. Seventy-three percent of patients in the United Kingdom with head and neck cancer are referred from primary care under the urgent or 2-week referral system. In the United Kingdom, the incidence of cancer with unknown primary is 10,000, many of these present as cervical malignancy with undiagnosed primary origin.
In our clinic, most presenting neck lumps are benign, with reactive or suppurative lymphadenopathy, lipomata, and superficial and deep cervical cysts. Benign disease of the parotid tail and submandibular and sublingual glands are also common presentations. Less frequent referrals relate to variations of normal anatomy: a prominent carotid bulb or a spinous process of cervical vertebra or a cervical rib.
The radiology team has an important role in the assessment and diagnosis of neck lumps. In particular, the ability of the radiologist to identify cancer spread and accurately stage malignancy is a key and often pivotal role in influencing treatment at the multidisciplinary team meeting. This situation has reflected the advances across the field of imaging in recent times. In this article, the imaging modalities available are reviewed, highlighting their merits and hurdles of use, and, second, the common and significant neck lumps presenting to our head and neck clinic are reviewed.
Anatomic classification of the neck
Cervical Lymphatic Classification
The extensive lymphatic system in the head and neck provides a physiologic mechanism for channeling fluid, cells, and protein from the interstitium into the systemic circulation. There are approximately 300 lymph nodes within this region, which account for 40% of the total body lymph nodes. An understanding of the head and neck lymphatic system is needed in the management of patients with head and neck cancer with regional metastasis. Lymphatics in the neck have been classified into superficial and deep systems ( Fig. 1 ). The superficial system arising in the reticular dermis and superficial cervical fascia and the deep lymphatic circulation functions beneath the investing layer of the deep cervical fascia ( Table 1 ). The American Head and Neck Society and American Academy of Otolaryngology–Head and Neck Surgery organized the cervical lymphatic system into separate levels, reflecting patterns of drainage ( Fig. 2 , Table 2 ). This division provides reproducible anatomic localization for both surgeon and radiologist.
| Cervical Triangle | Boundaries | Contents |
|---|---|---|
| Anterior | ||
| Submental | Neck midline Lower border of mandible Anterior belly of digastric muscle |
Submental vessels uniting with anterior jugular vein Level Ia lymph nodes |
| Submandibular | Lower border of mandible Anterior belly and digastric Posterior belly of digastric muscle |
Facial vessels Level Ib lymph nodes Submandibular gland Marginal mandibular branch of facial nerve Hypoglossal nerve |
| Carotid | Mid third of sternomastoid muscle (anterior margin) Posterior belly of digastric muscle Superior belly of omohyoid |
Bifurcation of common carotid artery Carotid branches (superior thyroid, lingual, facial, occipital, ascending pharyngeal) Internal jugular vein and tributaries (superior thyroid, lingual, common facial, ascending pharyngeal, occipital) Sympathetic trunk Vagus nerve Hypoglossal nerve Cervical plexus Spinal accessory nerve Level II/III lymph nodes Upper larynx/lower pharynx |
| Muscular | Lower third of sternocleidomastoid (anterior margin) Superior belly of omohyoid Median line of neck (hyoid to sternum) |
Carotid sheath (common carotid artery, internal jugular vein, vagus nerve, sympathetic trunk) Ansa cervicalis Inferior thyroid artery and vein Esophagus Thyroid gland Trachea Lower part of larynx Recurrent laryngeal nerve Level II/III lymph nodes |
| Posterior | Anterior border of trapezius Middle third of clavicle posterior border of SCM |
Transverse cervical vessels Distal part of subclavian artery Suprascapular artery Lower part of external jugular vein Level V lymph nodes Spinal accessory nerve Cervical plexus Phrenic nerve (C3,4,5) |
| Level | Anatomic Site | Draining Source |
|---|---|---|
| IA | Submental triangle | Lips, chin, nasal tip, incisors/canines |
| IB | Submandibular triangle | Cheek, premolar and molar teeth, anterior tongue |
| IIA | Base of skull to upper border of hyoid bone: anterior to SAN | Oropharynx, anterior and posterior tongue |
| IIB | Base of skull to upper border of hyoid bone: posterior to SAN | Oropharynx, parotid |
| III | Upper border of hyoid bone to upper border of cricoid | Oropharynx, larynx |
| IV | Upper border of cricoid to upper border of clavicle | Oropharynx, larynx, upper thorax |
| VA | Posterior triangle: anterior to SAN | Occiput and scalp |
| VB | Posterior triangle: distal to SAN | Occiput and scalp |
| VI | Lower border of hyoid to suprasternal notch. Lateral border is common carotid artery | Thyroid gland, larynx, piriform sinus, esophagus |
Consultation appointment
With the space constraints of this article, the full history taking and examination process are not considered. However, the importance of targeted questions relevant to diagnosis must be highlighted. The fundamental aim of the clinic is to identify the malignant conditions from most referrals that prove benign. Patients presenting with an undiagnosed malignancy may have been suffering local, regional, and systematic symptoms associated with local tumor behavior and metastatic and paraneoplastic effects. In addition, questions about B symptoms in suspected lymphoma are recommended. A careful social history analyzing tobacco and alcohol habits and details of past sexual practice assigns a level of risk to the patient.
Specific questions on renal function and allergy are required before referring for radiologic investigations requiring intravenous contrast. Inherited and acquired coagulopathies need to be identified before invasive sampling. We have found that increasingly more patients attending clinic report taking new-generation antiplatelets (eg, prasugrel, ticagrelor, clopidogrel). These antiplatelets can be easily overlooked but require appropriate discussion with hematology colleagues before investigative procedures and treatment.
A routine head and neck examination should be performed, which should include an oral examination and flexible nasal endoscopy. Clues from the history may encourage the clinician to examine the chest, axillae, abdomen, and nervous system.
Findings and recommendations from the Eighth Annual Review of Data Analysis of Head and Neck Oncology showed that only 80% of patients had TNM cancer staging and 66% performance status recorded at the time of multidisciplinary team discussion. The initial consultation is an ideal time to start collecting this information.
Imaging modalities in the assessment of neck lumps
Radiology is continually and rapidly advancing and forms a critical component of the diagnostic pathway for investigating neck lumps. Faster image acquisition, improved resolution, and expanding software capabilities all contribute to more detailed and more informative imaging.
The main imaging modalities used in the assessment of lumps presenting in the head and neck are US, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). An overview of their strengths and weaknesses is provided in Table 3 , with guidance related to image acquisition.
| Modality | Strengths | Weaknesses | Tips and Technique |
|---|---|---|---|
| US |
|
Operator dependent; neck US best performed by specialist head and neck radiologist Limited depth penetration Limited visualization of bony structures |
Patient scanned with neck extended High-frequency probe (8–12 MHz) |
| CT |
|
Uses ionizing radiation Requires intravenous iodinated contrast for optimum visualization of structures in the neck Image quality degraded by artifact from dental amalgam and swallowing Limited soft tissue characterization |
Scan during quiet breathing Slow intravenous injection of contrast (100 mL injected at 1 mL/s and scanned at 100 s) for arterial, venous. and soft tissue enhancement |
| MRI | Excellent soft tissue characterization No ionizing radiation |
|
Scan with quiet breathing Fat-saturated postcontrast T1 sequence makes pathologic enhancement more conspicuous Acquire diffusion-weighted sequence |
| PET/CT | Provides functional data regarding metabolic activity of the primary tumor and any metastatic disease Wider scan range (typically skull base to mid thighs or whole body) |
Expensive and limited availability High ionizing radiation dose |
Ultrasonography
US is commonly the first-line imaging modality for assessing neck lumps. It is a quick, well-tolerated examination, which is widely available and offers a high spatial resolution without the use of ionizing radiation. Furthermore, US allows real-time guidance for fine-needle aspiration (FNA) cytology (FNAC) and core biopsy when a tissue sample is required. The main disadvantages of US are that it is limited to relatively superficial structures and is user dependent, with a high level of expertise required for the assessment of neck disease. Image quality is improved if good neck extension can be achieved ( Fig. 3 ).
