NECK MASSES 245
1. Plain Films. A plain film of the neck should always be requested because
it will demonstrate such things as cervical ribs, laryngooeles, calcification in
old tuberculous glands, and tracheal compression or altered direction from
thyroid masses. A chest film may show pulmonary tuberculosis, mediastinal
gland enlargement, bronchial carcinoma or evidence of secondary spread.
Base of skull and lateral skull films should be done if nasopharyngeal
cancer is suspected.
2. Contrast Studies. Barium studies will demonstrate oesophageal and
gastric carcinomas or any oesophageal displacement. Defects in filling in the
pyriform fossa will also be seen.
Laryngography is useful in primary laryngeal pathology and sialography
must be done in salivary gland disease. Perhaps the most important contrast
study in neck masses is carotid angiography.
3. Scanning Techniques. Any thyroid mass demands a thyroid scan. A
follicular adenocarcinoma and its metastases take up radioactive iodine
whereas no other tumour does so. A cold area may thus be the site of a
carcinoma, but all nodules which are cold on scan are far from being
malignant as this appearance may be due to haemorrhage or to degeneration
in a cystic goitre. Hot nodules are never malignant.
Salivary gland scanning can be done with technitium. It is said that all
tumours are cold apart from Warthin's tumour which is hot. This test,
however, is technically difficult and the results are too variable to be useful.
LABORATORY TESTS. In thyroid masses all the thyroid function tests should be
All patients in whom surgery is contemplated should have a full blood
count, as should all those with the reticuloses. In cases where there are
multiple glands in the posterior triangle blood should be sent for a Paul-
Bunnell test, a toxoplasma titre, a brucella titre and a cytomegalovirus titre. If
tuberculosis or sarcoid is suspected a Mantoux test is done.
TREATMENT POLICY, If a definitive diagnosis is made the treatment is usually
straightforward, the inflammatory condition being drained if necessary and
treated with antibiotics, and the congenital masses and benign tumours being
The problem is greatest in the patient over the age of 40 with a hard mass in
the neck. This might be tuberculosis, a reticulosis or a metastatic cancer. If a
metastatic cancer is biopsied, the skin closed and the result awaited, before a
search is made for the primary site, the potential survival of the patient is
reduced by 66 per cent. For example, if a tonsillar cancer is silent and presents
with a lymph node the patient's chance of living for 5 years after treatment of
the primary is about 40 per cent. If the gland is biopsied with no concomitant
treatment of the primary tumour the patient's chance of survival drops to
about 14 per cent.
The way such a situation should be handled is to presume that the mass in
the neck is a cancer and to make every effort to find the primary. A full head
and neck examination should discover 85 per cent of the tumours and the
other 15 per cent should be searched for with chest and barium radiographs.
If this primary search is negative the next stage should be panendoscopy and
biopsies. In this procedure the patient is anaesthetized and a close examination
and biopsy are done of the nasopharynx, the base of the tongue and tonsil, the