Sandbox:Maneesha

Differential diagnosis of neck masses

Differential diagnosis of neck masses include:

Category	Diseases		Benign or Malignant	Clinical manifestation								Paraclinical findings			Gold standard diagnosis	Associated findings
				Demography	History	Symptoms		Signs				Lab findings	Histopathology	Imaging
						Pain	Dysphagia	Mass exam	Skin changes	LAP	Others
Congenital	Branchial cleft cyst		Benign	Age: 1-15 yrs/ varies Familial occurence is noted	Lateral neck mass	-	+/-	Solitary Smooth Mobile Welldefined Non-pulsatile Fluctuant	A pit is found at the opening of the cyst	-	-	-	Squamous or ciliated epithelial lining Lymphoid tissue with germinal centers and subcapsular sinuses	CT: Well defined fluid attenuation with slight enhancement of the capsule Ultrasound: Typical features of a cyst are seen		Brachio-oto-renal syndrome Sinus Fistula
	Thyroglossal duct cyst		Benign	Age: 1-10 yrs/ varies	Midline neck mass	-	-	Mobile Moves upwards with tongue protrusion and swallowing	-	-	-	-	Squamous or ciliated pseudostratified columnar lining Foci of thyroid gland tissue Granulation tissue or giant cells if it gets infected	Ultrasound: Anechoic, thin walls, and heterogeneous with internal septae CT with contrast: Well circumscribed,homogeneous fluid attenuation, thin enhancing rim MRI: T1- dark, T2-bright images		-
	Haemangioma		Benign	Age: birth - 2 yrs Females>males	Presents with a flat red or purple patch	-	-	Firm Rubbery Well-demarcated	Blanching Telangiectasias Erythematous patch	-	Regress gradually with age	GLUT-1 VEGF	Lined by non atypical endothelial cells Vascular structures with RBC	Ultrasound: High flow with vascular channels MRI: With or without Gd is the modality of choice		POEMS and Castleman's disease
	Vascular malformations		Benign	Incidence: 1 in 2000 to 5000 births Sex: No predilection	Venous: Present with a bluish swelling AV malformations: Present with purple/red swelling	-/+	-	Soft Compressible Non-tender Venous: No thrill,↑ in size on valsalva AV malformations: Thrill, warm, pulsatile	-	-	Grow proportionally with age	↑ D-dimer level in venous malfomations	Lined by single endothelial layer	Doppler ultrasound: Venous malformations show slow flow, hypoechoic, AV malformations show high flow MRI with Gd: Diffuse enhancement	MRI	-
	Lymphatic malformations		Benign	Age: Birth - 5yrs Sex: No predilection	Presents with a large swelling mainly in the neck	-	+	Soft Non-compressible Non-pulsatile Fluctuant Transillumination+	-	-	Never regress, expand/contract based on inflammation	-	Dilated lymphatic channels lined by endothelial cells Positive D2-40 stain	Ultrasound: Hypo/anechoic with thick septa and fluid CT: Homogeneous and cystic mass MRI: Hyperintense on T2 & peripheral wall enhancement on T1		Down syndrome, turner syndrome
	Laryngocele		Benign	More common in adults Male: female = 5:1	Presents with a neck swelling, hoarseness, stridor and globus sensation Episodic in nature	-	+	Soft Reducible Increase in size on valsalva	-	-	Common in glass blowers, trumpet players	-	Lined by pseudostratified ciliated epithelium	X-ray, CT: Fluid and air containing cystic masses CT is the preferred one Direct laryngoscopy	CT scan is the gold standard imaging for diagnosis	-
	Ranula		Benign	Age: 1st and 2nd decade Female: male=1:1.4	Presents with a blue colored swelling in the floor of the mouth	-	-	Well circumscribed Fluctuant Soft	-	-	-	-
	Teratoma		Benign/malignant	Incidence: 1:4000 births Sex: No predilection	Presents as a firm lateral neck mass	-	-	Firm Non-tender	-	-	-	High ALP levels	Shows ecto, meso and endodermal tissues	CT & MRI: Shows calcifications
	Dermoid cyst		Benign	Incidence: 3 per 10000 population Age: birth - 5 yrs	Presents as a slow growing mass or a sinus	-	-	Freely mobile Solitary Rubbery Nonpulsatile Noncompressible	Usually normal/sometimes a pit or sinus is seen A tuft of hair at the center of the pit for nasal dermoid cyst	-	-	-	Keratinizing squamous epithelium Occasional remnants of hair follicles, adipose tissue, and sweat glands	Ultrasound: Thin walled, unilocular CT: With contrast well circumscribed, unilocular, sac-of-marbles appearance due to fatty tissue
	Thymic cyst		Benign	Age: 1-10 yrs Males>Females	Presents as a soft mass, gradually enlarging, on left side of the neck(usual)	-	-	Soft Compressible	-	-	-	-	Squamous/cuboidal epithelium Lymphoid tissue in the cyst wall contains hassall corpuscles	Ultrasound: Unilocular cystic mass CT: Uni/multilocular, well circumscribed and nonenhancing
Category	Diseases		Benign or Malignant	Demography	History	Pain	Dysphagia	Mass exam	Skin changes	LAP	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Inflammatory	Acute sialadenitis		Benign	Age:Occurs in all age groups Sex: No predilection	Presents with an unilateral erythematous swelling Bad breath Fever with chills	+	-	Tender Firm Purulent discharge expressed from the duct Smooth	Redness	+	More common in people with bad oral hygiene	↑ ESR Leukocytosis	Inflammatory infiltrate with microabscess formation	Ultrasound: Hypoechoic with ductal dilatation CT: Diffuse homogeneous enlargement	CT scan
	Chronic sialadenitis		Benign	Age:Occurs in all age groups Sex: No predilection	Presents with an unilateral swelling Recurrent episodes common	+	-	Non-tender Firm Smooth	-		Mostly due to obstruction by a stone or stricture	↑ ESR Leukocytosis	Hyperplastic lymphoid infiltrates with loss of salivary gland acini Fibrosis	X-ray: Shows radiopaque stones CT: Parenchymal volume is ↓	CT scan
	Reactive viral lymphadenopathy	CMV	Benign	Age: 10-35 yrs mainly Sex: No predilection	Flu-like illness	-	-	Non-tender Soft	-	Generalized/cervical	-	↑ESR ↑SGOT/SGPT	H&E stain: Typical owl-eye inclusions(nuclear) Basophilic cytoplasmic inclusions	Usually not necessary	FNAC & serology
		EBV	Benign	Age: Mainly adolescents Sex: No predilection	Sore throat Fever Malaise Lymphadenopathy	-	-	Non-tender Firm	-	B/L posterior cervical, axillary, inguinal	-	Atypical lymphocytosis + Monospot test IgM & IgG antibodies against VCA EBV ↑↑SGOT/SGPT	CD8+ lymphocytes Tissue necrosis B lymphocyte blasts	Usually not necessary	FNAC & serology
		HIV			Flu-like illness Rash					Generalized
		Viral URI	Benign		Sore throat Cough Runny nose	-	-	Non-tender		Mild cervical		Lymphocytosis ↑ESR & C-reactive protein		No specific findings
	Bacterial lymphadenopathy	Tularemia	Benign	Age: Affects all age groups Sex: No predilection	Fever Chills Swelling Joint pains	+	-	Tender Edematous	Ulcer/rash Redness	Regional	-	↑ESR ↑C-reactive protein	Caseating granuloma +/- multinucleated giant cells	No specific findings	PCR & serology
		Brucellosis	Benign	Incidence: 100-200 cases anually in USA Sex: Males>females	Flu-like illness	+	-	Tender	-	Cervical		↑ESR	Non-caseating granuloma+ giant cells, epitheloid cells	No specific findings	Serology
		Cat-scratch disease
		Actinomycosis
		Mycobacterial infections
		Staphylococcal or streptococcal infection
	Parasitic lymphadenopathy	Toxoplasma gondii
	Sarcoidosis
	Amyloidosis
	Sjögren syndrome
	Castleman disease (angiofollicular lymphoproliferative disease)
	Kikuchi disease (histiocytic necrotizing lymphadenitis)
	Kimura disease
	Rosai-Dorfman disease
	Kawasaki disease
Category	Diseases		Benign or Malignant	Demography	History	Pain	Dysphagia	Mass exam	Skin changes	LAP	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Primary thyroid tumor
	Salivary gland neoplasm	Pleomorphic adenoma	+
		Warthin's tumor	+
		Lymphoepithelioma	+
		Oncocytoma
		Monomorphic adenoma
		Mucoepidermoid carcinoma
		Adenoid cystic carcinoma
		Adenocarcinoma
		Salivary duct carcinoma
		Squamous cell carcinoma
	Parathyroid tumors
	Carotid body tumors
	Paraganglioma
	Schwannoma
	Lymphoma
	Liposarcoma
	Lipoma
	Glomus vagale, glomus jugulare tumors
	Metastatic head and neck carcinoma
Other	Hematoma
	Arteriovenous fistula
	Goiter
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Skin changes	LAP	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings