Tumors and pseudotumors in the neck

Abstract

If a mass moves upward on swallowing, it is either an enlarged thyroid gIand or it is connected to the thyroid. If a mass moves upward on protruding the tongue, it arises from the thyrogIossa1 duct. MuItipIe sweIIings are almost aIways found to be enIarged lymph nodes. If pressure over a sweIIing in the neck causes fluid to appear in the throat, one should be suspicious of a branchial fistuIa or esophageal diverticulum. If a mass pulsates in a11 directions (expansiIe pulsation), it is probably an aneurysm. VascuIar swellings are compressible whether neoplastic or not. Diverticuli of the esophagus or pharynx empty on pressure. Cystic hygroma may seem to compress if deep IocuIi are present. Ptosis, OphthaImopIegia and a mass of secondary enIarged nodes in the neck may indicate a primary Iesion in the nasopharynx.* The tonsillar lymph node, Iocated just under the angIe of the mandibIe, may be involved rareIy by tubercuIosis but commonly by drainage from infected tonsiIs.35 MoIlison states that when a patient presents himseIf with a hard lump in the neck and cotton in the ear, he is probabIy suffering from carcinoma of the deep pharynx.4 Draining fistulas on the IateraI side of the neck are commonly due to branchial fistulas; those in the midline anteriorIy are due to thyroglossal fistulas. PuIsation may be transmitted in one direction from underIying arteries which have no connection with the mass (transmitted puIsation), from an artery which is adjacent to the mass (carotid body tumor) or may be mimicked by the expansile puIsation of an aneurysm. When one feels a mass that is fixed, the first impuIse is to assume that it is of a maIignant nature.6 ActuaIIy inflammation early fixes a sweIIing. In contrast, malignant tumors are not fixed unti1 infiItration occurs. If the edge of a mass is sharp and cIearIy defined, consider first a benign tumor. Inflammation is suggested by poorly defined margins and maIignant tumors by intermediate gracles of fixation.’ A hard sweIIing may resuIt from a streptococcal or staphyloccal infection or from a neopIasm.6 A tender mass indicates that increased tension is present and that inAammation is the probable cause, although a rapidly enlarging neopIasm may be tender, either in the neck or the breast. A warm sweIIing has the former significance. It is not uncommon for a patient to complain of a sweIIing in the neck and for the physician not to be abIe to detect one. The patient may have feIt a norma structure in the neck, as for example the hyoid bone, or he may be abIe to fee1 a minute swelling before the physician is abIe to do so. Re-examination in a week or two will tend to cIear the issue. Consistency is not an altogether reliable sign in neck swelIings. An adenoma of the thyroid is paradoxic as far as fluctuation is concerned; the soIid variety feels cystic and the cystic variety feels soIid.2 Put on dark glasses, used in Auoroscopic eye adaptation, and examine the neck and anterior chest wall for dilated veins. Dilated veins noted on the upper chest waI1 may be due to a retrosternal goiter and pressure on the interna juguIar vein or to a mediastina1 tumor. The sign of emptying indicates a diagnosis of cavernous hemangioma.4 If a sweIIing of the neck appears when the patient brows his nose, one must consider IaryngoceIe, a narrow necked pouch connected with Iarynx. To determine the depth of a IateraI cervica1 sweIIing one must determine whether it is inferior or superior, superhcia1 or deep, to the sternomastoid muscIe. Stand behind the patient and ask him to push his chin firmIy against your hand. This procedure tenses the sternomastoid