Lump in the Neck – April 2011

Case Report

Mr. John C., a 55-year old, noticed a bump in his left upper neck while he was shaving off a beard he had grown months ago.  The growth did not cause pain when touched, was beneath his earlobe under the skin surface, and felt like a small, rubber ball.  His regular physician sent him to an ENT surgeon who recommended a “FNA” (fine needle aspiration), a technique whereby a tiny needle is placed within the lump under a local anesthetic, and cells are drawn out for analysis.

John was called by his surgeon two days later when the lab had processed the tissue for analysis, and was told the mass was a non-cancerous (benign) growth called a “pleomorphic adenoma”.  It was explained this was a tumor that forms in the salivary gland called the “parotid” high in the neck on either side of the face.

A day surgery was recommended and performed through a cosmetic incision in the crease in front of the ear, and the growth successfully removed.  The surgery took two hours since care had to be taken to avoid injury to the facial nerve, which runs through the core of the parotid gland.

“Lumps” (masses) in the neck are reason for significant concern as a rule.  While most of these growths are not cancerous, any mass in the neck, even those that do not cause pain or symptoms, should be evaluated, especially if they do not disappear within a few weeks  For sake of simplicity, I will classify neck masses into a few categories:

  1. INFLAMMATORY:  Each side of the neck contains over 30 lymph nodes.  These are often erroneously called “glands”…lymph nodes are small, soft coffee-bean sized structures that filter impurities from the lymph channels of the body.  Bacteria and other microscopic matter can get trapped in the nodes and cause them to enlarge  Lymph nodes typically enlarge with a cold, flu, disease like mono, sinus or ear infections or sore throats.  In fact, any infection or irritation of  the ear nose and throat system, or facial skin, can cause neck nodes to become swollen.  This is of no concern if they return to normal size within a few weeks.Benign cysts can form under the skin and become irritated or infected.  These can be treated with antibiotics, hot soaks, and occasionally need to be removed surgically.
  2. CONGENTIAL:  There are a few classic neck growths that are present since birth, but may not become apparent for years.  Thyroglossal duct cysts form in the midline of the neck in a line from under the chin to the Adam’s apple (thyroid cartilage).  They almost never become cancerous, but can become unsightly or infected.  Treatment is surgical removal.  Branchial Cleft Cysts form on the side of the neck in front of the muscle that stretches from the ear to the collar bone.  They also rarely become cancerous, and should be removed surgically.
  3. NEOPLASTIC(“neoplasia” means “new growth” in Latin):
    • Salivary glands are located in front and under the ear (parotid) and under the jaw (submandibular).  These glands that make saliva can form benign and cancerous growths.  Both types should be removed surgically, since both growth continuously, and the benign version can transform into cancers.
    • Lymph nodes in the neck can form cancers called “lymphoma” and “Hodgkins Disease”.  While removal of the effected nodes does not cure the disease per se, it can lead to a diagnosis allowing proper treatment.  Lymph nodes can also be invaded and overtaken by cancer cells that spread from other parts of the head and neck.  Cancers of the throat, voice box, thyroid gland, nasal passage and other regions can spread to lymph nodes of the neck.
    • Thyroid tumors:  the thyroid gland is a “butterfly-shaped” gland under the Adam’s apple.  It can form benign growths as well as malignant.  These should be promptly evaluated.

The ENT surgeon, when confronted with a patient’s neck mass, will act quickly to determine whether there is concern for malignancy.  The evaluation includes a thorough head and neck exam by the specialist.  This may be followed by fine needle biopsy, CAT or MRI scanning, or surgical removal.  The greatest mistake a patient or doctor can make in this setting is to assume a neck mass is not threatening.  This determination should always be reached AFTER a thorough evaluation.

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