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Cervical Masses

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The neck is an anatomic area of the human body, where gather, we would say, many important anatomic elements and organs. Each of them can cause a swelling in the neck, of inflammatory or neoplastic origin, which we will be called to diagnose first and then treat either conservatively or surgically.

The large blood vessels, jugular vein and carotid artery, with their neuroendocrine organs, the cerebral nerves with their epineural sheath, the lymph glands and the fat tissue, the muscles and other organs like the larynx, the esophagus, the salivary glands, the thyroid, all these can cause a swelling in the neck. To the above we should add the fetal remnants which may swell any time during the adolescent or adult life of an individual. So, the head and neck surgeon will be called to diagnose and treat any swellings of congenital origin, like branchial cyst, thyroglossal cyst, and dermoid cyst, of neurogenic origin, like neuroma or schwannoma, lipomas, tumor of the carotid body and lymphatic swellings of either pathological or neoplastic origin.

The history of the patient is the first thing the doctor looks into. The time of appearance of the swelling in the neck, the connection of its appearance to other incidents, like a viral infection or an injury, or to the symptoms in other organs is information which the doctor must know. What follows next is the clinical examination which locates the position of the swelling, its composition, its mobility, the presence of bruit and other information. Regardless of the swelling itself, the clinical examination will be extended to the entire head and neck and will also include the endoscopic check up of the nose, the nasopharynx and the larynx.

From the history and the clinical examination, the doctor should already have decided about the identity of the swelling, at least in the majority of the cases. Some cervical masses however, such as the lymphatic swellings of inflammatory origin, demand, for their investigation and treatment, the cooperation with other specialties, like mainly that of Internal Medicine. In such cases, and before we proceed with a lab or pictorial check up, it is advisable to refer our patient for assessment by an internist.

The haematological examination will give us a picture of the general condition of the patients health, while some special haematological examinations or the trace of antibodies against viruses, may even reveal the origin of the cervical mass, like in the case of swollen lymph nodes of inflammatory origin.

The first imaging examination which must be required is the ultrasonography of the neck. An easy and painless examination, in the right hands it can give us information, not only comparable to those provided by CT or MRI, but also to suggest even the histological identity of the swelling. In isolated cases, it will be necessary to complete the imaging examination with a CT and, rarely, an MRI. These exams should be made after administering a contrast or paramagnetic substance respectively. The imaging examination will inform us about the size of the swelling, if it is firm or cystic, and its relation to the large blood vessels of the neck or other important organs. This information will also help in the decision for a potential operation for the removal of the tumor.

After the imaging examination is complete, we have gathered enough information, in order to be able, in most of the cases, to proceed with the therapeutic treatment. In certain cases, however, we need to know the histological identity of the swelling, like, for example, when we are going to practice extensive amputation surgery, as is the case with neck nodes dissection. In these cases, we aspirate the swelling. This aspiration, performed with a thin needle, and the sample taken for cytological examination (FNA) can, in most cases, reveal the histological identity of the swelling.

If the FNA does not give the expected results, it is preferable to be repeated, rather than practice open biopsy. Open biopsy has the disadvantage of invading the tumor borders and, in the case of malignancy, may lead to an undesirable spread. In special cases, however, like lymphoma, open biopsy may be necessary. The incision for open biopsy has to be such that, at a later time, to be able to be extended for the total removal of the mass, or for a neck dissection.

After the diagnostic tests are completed, a decision is made for the therapeutic treatment of the swelling. If the prescribed treatment is conservative, the patient will be referred to a colleague of a respective specialty. If the treatment is surgical, then the patient should be informed about the kind of the suggested surgery and its potential complications. The neck is an anatomical area with a plethora of vital organs. This means that nothing can be removed or harmed without serious consequences in most of the cases. The experience of the surgeon has to be large, and this presupposes a systematic, and not occasional, dealing with the area at hand.