Progressive neck mass

Introduction A neck mass is one of the most common diseases in the neck. Foreign scholar Skondalakis has concluded an "80% regularity" in the diagnosis of neck masses: 1 For non-thyroid neck mass, about 20% belong to inflammation and congenital diseases; and the remaining 80% belong to true tumors. 2 For patients with true tumors, about 20% are benign tumors, 80% are malignant sources; at the same time, gender is related, women account for about 20%, and men account for 80%. 3 In neck malignant tumors, 20% are primary to the neck, and the vast majority are metastases (80%) derived from malignant tumors in other parts of the body. 4 80% of the metastases in the neck are from the head and face, and 20% are from the trunk of the human body. It must be noted that about 20% of all metastatic cancers in the neck, despite clinical, imaging, cytological and laboratory tests, eventually found no primary lesions, even occult Cancer.

Cause

The neck mass is a clinical sign, the reason is more complicated, involving the internal, external, oral, otolaryngology and other subjects, should be identified to avoid misdiagnosis. Apply the anatomical neck to connect the head and chest, the upper skull base, the lower chest entrance, and the 1st to 7th cervical vertebrae. The neck range is not large, but it contains important organs such as pharynx, larynx, trachea, canteen, thyroid, carotid artery and vagus nerve. The main contents are as follows:

1. Neck muscles: The neck mainly has the following muscles: the sternocleidomastoid muscle is located on the outside of the neck, one on each side. The starting point has two ends, starting from the surface of the sternum stem and the inner side of the clavicle, obliquely upward, ending on the surface of the mastoid and the outer side of the occipital line, mainly dominated by the accessory nerve. The sternocleidomastoid muscle is well-developed and is an important muscle marker in neck surgery. The carotid artery, internal jugular vein, and vagus nerve are located deep inside. The hypoglossal muscle includes the sternohyoid muscle, the thyroplasty, the thyroid sternum, and the scapula. There are 4 pairs on both sides. The upper end of the sternohyoid muscle is located at the lower edge of the hyoid bone, and the lower end is attached to the sternum stem. The earliest position in the subosseous muscle, the muscle is flat. The sublingual muscles are located in front of the larynx, trachea, and thyroid gland, and are closely related to surgery such as the larynx, thyroid, and tracheotomy. There are muscles such as the abdominal muscles and trapezius muscles in the neck. With the sternocleidomastoid as the boundary, the neck is divided into two triangles: the anterior and posterior neck; the former is divided into the inferior triangle, the lower jaw triangle, the carotid triangle and the muscle triangle, while the latter contains the occipital triangle and the clavicle. Upper triangle.

2, the neck blood vessels and nerves.

(1) Artery: The common carotid artery is located in the deep part of the cytoplasmic mastoid muscle. It is divided into two parts, the external carotid artery and the internal carotid artery, at the level corresponding to the large angle of the hyoid bone. The external carotid artery has branches of the superior thyroid artery, the facial artery, the maxillary artery and the superficial temporal artery. It is an important source of blood supply for the head and neck structure. The internal carotid artery enters the cranium through the ruptured hole, and there is no branch in the neck. The external carotid artery and the internal carotid artery must be distinguished during neck surgery.

(2) Venous: The external jugular vein is located on the surface of the sternocleidomastoid muscle. The internal jugular vein is a continuation of the intracranial sigmoid sinus. It is located at the deep side of the scapula and is the main path for venous return of the head and face.

(3) Nerves: The vagus nerve walks along the common carotid artery and internal jugular vein in the carotid sheath. The recurrent laryngeal nerve is one of the branches of the vagus nerve. It moves up the posterior aspect of the common carotid artery along the tracheal esophageal sulcus. It is responsible for the movement of the larynx muscle outside the circumflex muscle. When neck surgery, especially thyroid surgery, it should be avoided. The accessory nerve innervates the sternocleidomastoid muscle and the trapezius muscle. Enter the sternocleidomastoid muscle at 3 to 4 cm below the mastoid tip, and pass the posterior margin of the mid-muscle to cross the posterior triangle of the neck to the trapezius muscle. Peripheral nerve surrounding lymphoid tissue is rich, radical cervical lymph node dissection, cut off the accessory nerve and cause trapezius tendon, affecting shrug and upper limb lift function. The hypoglossal nerve straddles the carotid bifurcation and has descending branches associated with the common carotid artery. The hypoglossal nerve causes atrophy of the tongue muscle.

3, the lymph nodes of the neck and neck are rich, can be divided into subarachnoid, submandibular, anterior cervical, superficial lateral and deep lateral cervical lymph nodes. The submandibular lymph nodes receive lymphatic reflux in the nose, sinuses, mouth, cheeks, etc., and inflammation or malignant tumors in the above sites often invade the submandibular lymph nodes. The deep cervical lymph nodes are closely related to the internal jugular vein. The carotid bifurcation is the boundary, and the deep lymph nodes on the lateral side of the neck and the deep lymph nodes on the lateral side of the neck. Lymph node metastasis of head and neck malignant tumors such as nasopharyngeal carcinoma occurs mostly in the lateral deep lymph nodes of the neck; deep cervical lymph nodes in the lateral neck are excluded from the deep lymph nodes on the lateral side of the neck, and sometimes chest cancer such as esophageal cancer can be transferred to the lateral side of the neck. Deep lymph nodes. The axillary lymph nodes are located in the lower part of the triangle and receive lymphatic reflux at the bottom of the mouth. The anterior and lateral cervical lymph nodes are located near the jugular vein and the external jugular vein.

4, pharyngeal space: the deep fascia of the neck is covered in the neck muscles, blood vessels, nerves and the surface of organs such as the pharynx, larynx and thyroid, and forms the pharyngeal space, such as the posterior pharyngeal space and the pharyngeal space. The posterior pharyngeal space is located between the posterior pharyngeal fascia and the anterior vertebral fascia. The upper part of the sac is the base of the skull. The medial side of the parapharyngeal space is the pharyngeal side wall, the lateral side has the parotid gland, the upper skull base, down to the hyoid bone, and the posterior aspect is the cervical transverse process. With the styloid process as the boundary, the parapharyngeal space is divided into two parts: the anterior and posterior parts, the anterior wing muscle, the posterior part contains the carotid sheath, etc.; when the parapharyngeal space has a space-occupying lesion, the large vessel of the neck can be moved. Bit.

an examination

Related inspection

Thyroid B-mode ultrasonography thyroid imaging

In order to clarify the cause and nature of the neck mass, the following points should be noted in the diagnosis:

1, detailed medical history

Including age, gender, duration of disease, severity of symptoms, treatment effect, and clinical manifestations of organ involvement such as nose, pharynx, larynx, and oral cavity, or systemic symptoms such as fever and weight loss.

2, clinical examination

First of all, pay attention to observe whether the necks on both sides are symmetrical, whether there is local swelling or fistula formation. Then the neck is diagnosed. At the time of examination, the subject's head is slightly lower, and the side of the patient is inclined to relax the neck muscles, which is convenient for the bumps. Pay attention to the location, size, texture, activity, presence or absence of tenderness or pulsation of the mass, and compare it with the two sides. As mentioned above, adult neck masses should consider metastatic malignant tumors. Therefore, routine examination of the ear, nose, throat, mouth, etc., in order to understand the presence or absence of primary lesions in the nasopharynx, throat, etc. Endoscopic or fibrous nasopharyngoscopy can be performed if necessary.

3, imaging examination

CT scan of the neck can not only understand the location and extent of the tumor, but also help to determine the relationship between the tumor and the important structures such as carotid artery and internal jugular vein, which provides an important reference for surgical treatment, but the smaller mass is often unable to develop. In order to find the primary lesion, X-ray film examinations such as sinus, nasopharynx and larynx can be performed as appropriate. For the neck split fistula or thyroglossal fistula, it is feasible to check the X-ray film of the iodized oil to understand the direction and extent of the fistula.

4, pathological examination

(1) Puncture biopsy method: a small needle is inserted into the mass, and the tissue obtained after vigorous suction is subjected to cytopathological examination. Applicable to most neck lumps, but the tissue obtained is less. When the test is negative, it should be combined with clinical examination for further examination.

(2) Cut biopsy: it should be used with caution. Generally only when the diagnosis is not confirmed after repeated examinations. A single lymph node should be removed completely during surgery to prevent the spread of the lesion. When suspected tuberculous cervical lymphadenitis, after the biopsy is cut, it may lead to long-term failure of the wound, and attention should be paid to prevention. For patients with clinically diagnosed parotid-derived or neurogenic benign tumors, due to the deep tumor location, preoperative biopsy is not easy to obtain positive results, but it has the disadvantage of making the tumor adhere to surrounding tissues and increasing the difficulty of surgery. Pathological examination was performed after surgical removal of the tumor.

Differential diagnosis

According to the cause of the disease, the neck mass is generally divided into three categories: congenital, inflammatory and neoplastic. The clinical features of common neck masses are described below:

1, thyroglossal cysts are more common in children and adolescents. It is a congenital dysplasia. During embryonic development, such as thyroid gland degeneration, between the blind hole and the thyroid isthmus, a thyroglossal cyst can be formed. The mass is located between the midline of the neck, the thyroid cartilage and the hyoid bone, and often moves up and down with swallowing action. A fistula can be formed after infection and there is a mucus or mucopurulent discharge. The fistula is not easy to heal or often re-infected.

2. The cleft palate is a congenital dysplasia. At the embryonic stage, neck development is closely related to the evolution of the zygomatic arch and cleft palate. The zygomatic arch is an arched bulge that is propagated from the mesoderm and is arranged in parallel, with a total of 5 pairs. There are 4 pairs of splits composed of ectodermal epithelium between the arches. Under normal circumstances, the zygomatic arch and cleft palate eventually become the structure of the neck muscles and blood vessels. If the development is abnormal, a cleft palate or fistula is formed. The cyst is located on the outside of the neck and deep in the sternocleidomast muscle. Round or oval, the size is uncertain. After the infection is broken, a fistula can be formed in the neck, which is a cleft palate cyst and a fistula outside the fistula. Sometimes the cyst or fistula has an internal mouth that communicates with the external auditory canal, tonsil or piriform fossa.

3, acute, chronic cervical lymphadenitis, nose, pharynx, throat, mouth and other areas of inflammation, can cause cervical lymphadenopathy. Acute lymphadenitis, red, swollen, pain, heat and other acute inflammation characteristics, onset fast, often accompanied by fever, local tenderness, swelling subsided after anti-inflammatory treatment. Chronic inflammation of the cervical lymph nodes, long course, mild symptoms, often located in the submandibular area, small lymph nodes, active, tenderness is not obvious.

4, cervical lymph node lesions are primary, or secondary to tuberculosis lesions in the lungs, abdominal cavity, etc. The course of the disease is longer. Patients with mild disease, less local symptoms, unilateral or bilateral cervical lymph nodes, often stringy, medium quality, active, no tenderness. When the condition is severe, several lymph nodes can stick together to form a group. If the lymph nodes are dry and necrotic, the fistula is formed after the ulceration, and it will not heal for a long time.

5, AIDS neck lymphadenopathy, one of the clinical manifestations of pre-AIDS. Invaded by cervical lymph nodes by human immunodeficiency virus. The course of disease is longer, and the lymph nodes gradually increase, often accompanied by multiple lymph nodes such as abdominal muscle sulcus, fever, weight loss, fatigue, and leukopenia. Fine needle biopsy can assist with diagnosis.

6, more common in women with thyroid adenoma. Located in the front of the neck, the growth is slow, the symptoms are not obvious, often unintentionally found. The mass is moderate and moves up and down with swallowing action. A large thyroid adenoma can affect breathing due to tracheal displacement or compression of the trachea. If the mass increases rapidly, it is nodular, hard, involving the recurrent laryngeal nerve or infiltration into the trachea, causing difficulty in breathing, vocal cord dyskinesia, hoarseness, etc., thyroid cancer may be considered.

7, mixed with parotid gland is more common in the parotid gland. It is characterized by a lump under the earlobe, slow growth, no obvious symptoms, and is often found occasionally. The position of the mass is deeper, the surface is smooth, the quality is medium, and the push is movable. When the mass develops inward and invades the parapharyngeal space, the nasopharynx, oropharynx wall can be moved inward, or the soft palate can be bulged. If the mass is fixed, hard, local pain, or involving the facial nerve, there may be malignant changes in the mixed tumor.

8, neurogenic tumors. Most of them are schwannomas, which originate from Schwann cells on the nerve sheath, often occurring in the neck cutaneous nerve, sympathetic nerve, vagus nerve and so on. The tumor is located in the upper part of the lateral aspect of the neck, deep in the sternocleidomastoid muscle. With a round or round shape, the surface is smooth. Slow growth, when the lesion range is small, often no obvious symptoms. When the tumor is large, it can protrude to the pharynx, so that the pharyngeal wall is moved and full, and when it is severe, it can affect the breathing. Occasionally, it can be malignant, manifested as a rapid increase in tumors in the short term, or with signs of vagus, hypolingual nerve palsy.

9. Carotid body tumors originate from the carotid body. Located at the carotid bifurcation. When the tumor is small, the symptoms are not obvious. Such as invading the vagus, sublingual nerves, etc., can cause vocal cord movement disorders, tongue deflection and other signs. During the examination, the tumor can move with the artery, and the percussion has a feeling of pulsation. CT-enhanced scanning and angiography can help diagnose.

10. Malignant lymphoma. It is a malignant tumor that occurs in lymphatic network. The main manifestation is swollen lymph nodes, or a mass is formed in the extra-lymphatic tissue, and then the adjacent lymph nodes are involved. According to the cell morphology and degree of differentiation, it can be divided into two major categories: Jiejin and non-Hodgkin's lymphoma. Cervical lymphadenopathy is a common symptom of non-Hodgkin's lymphoma. The mass is painless, progressively enlarged, hard and early, and the lymph nodes stick to each other at a later stage, which is difficult to promote. If there are lesions in the tonsils, nasopharynx, and tongue roots, symptoms such as nasal congestion, nasal discharge, pharyngeal discomfort, and hearing loss may occur. Because of the enlargement of cervical lymph nodes caused by Hodgkin's lymphoma, it is mostly bilateral, and has systemic symptoms such as fever, hepatosplenomegaly, weight loss, and fatigue.

11. Metastatic malignant tumors Malignant tumors of the neck are one of the causes of neck masses, and the primary lesions are mostly located in the head and neck. Nasopharyngeal carcinoma has early cervical lymph node metastasis, sometimes the first symptom of nasopharyngeal carcinoma. More invading the deep lymph nodes on the lateral side of the neck, the enlarged lymph nodes are located behind the mandibular angle, gradually increasing, sometimes fused into a mass. Hard, poor activity, no tenderness. Often unilateral, but also bilateral cervical lymph nodes at the same time. The cervical lymph node metastasis of tonsil cancer is similar to that of nasopharyngeal carcinoma. Laryngeal cancer also often has cervical lymph node metastasis. The glottic type is particularly prone to occur. Most of the early stage is the lateral cervical deep group, the carotid bifurcation is swollen, and the metastatic lymph node cancer can be lowered to the lower stool angle or the collarbone. Zone expansion. Lymph node metastasis of nasal cavity and sinus cancer often occurs in the late stage of the lesion, and the enlarged lymph nodes are mostly located in the submandibular area. Lung cancer, esophageal cancer and other diseases, sometimes metastatic lymph node cancer in the supraclavicular region.

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